David Antezana, M.D. – “Neurosurgical Hybrids and Serving the Community”


>>David Antezana: Great, so. Julian, by the way,
that was a great talk. So and — concerned I learned something
while disturbing about myself along the way. [unintelligible] — [laughter]>>David Antezana: Any case — that
was a great — actually wonderful talk. And mine’s probably going to be
completely 180 in a different kind of talk, which will show that
you — in private practice, which, I mean you don’t need intellect. So I don’t need
intellectual freedom necessary. [laughter]>>David Antezana: But any case, as said,
my name’s David Antezana and I’ll start talk by asking the question,
where’s the — here we go. Why are we here? Well, you can — there’s no cosmic —
not meant to be a cosmic question or a spiritual, religious one. That’s — Sistine
Chapel there in Rome there. It’s more just a simple one. And back when I was here, kind of
look out and as [unintelligible] corrected, ’89 — 1989 seems a
long time ago for sure a lot of you. Maybe some of you may or
may not have been born. I don’t know. But I remember very well what
it was like to be your age. And I think the old picture that I have,
which I wanted to put up here from — that I still have, that
one that you just had taken, was outside, little cooler day. The make-up probably
looked about the same. But since we just
moved in this last year, it’s hanging out under a bunch of
pictures that I probably still have to get to. But for some of you, many of
you looking from past to present, there, you know, how we got, you know,
the question is so how did I get here? How could many of you —
one path that you might take. Well I — after — you know, I was born
and raised high school and college all inside city limits. Went to a little Benedictine monk school
that most of you have never heard of: St. Anselm’s. But still, you keep the old ties. I went down the street to
Catholic University of America, the alma mater of Joe Gibbs, actually. I’m proud to say he got his
bachelor’s, his master’s, and his Ph.D. all at Catholic University. And one of the reasons — probably the
only reason he actually took me into his lab. But I spent two wonderful
summers, starting in ’89, with Dr. Gibbs. And think one of the
beautiful things about the NIH, which many of you will
see, is, like St. Anselm’s, it was probably the last, you know —
I’ve been used to being surrounded by people that are a lot
smarter than I am my entire life. That includes my career. But really at — here at NIH, with Dr.
Gibbs’ lab and with also with the monks at St. Anselm’s, being surrounded by
such intelligent people that really can make you feel like you want to drive and
do more — and who so benign towards you and, you know, your presence
there and wanting to help you. That will go on as life goes on, but
I don’t think you might find it as ubiquitous when you move on
a little further in life. And so on, I made my way to University
of Minnesota before coming back closer to home, to Johns Hopkins, then
running off to the Oregon Clinic. So, and one of the things I should
thank all of you — also mention to — inviting me. My mom wanted to say thank you
for inviting me — [laughter]>>David Antezana: — because it means I
got to come over and stay with her for a day after living so
far away in Portland, so. Now, one of the things that I did
while I was in the summer program, I was in the Surgical
Neurology Branch myself. I was in the Laboratory of
Central Nervous Systems Studies. And what most of you
would not remember kuru, but you might remember mad cow disease. And one of the things that we studied
in that lab and that I was involved in, was the characterization of prions;
protonation infectious particles that play a part in the — in what we
call the transmissible spongy form encephalopathies. These are kuru,
Creutzfeldt-Jakob disease, bovine spongiform encephalopathy, the
mad cow disease that many of you heard of, and finally, scrapie. Now kuru is pretty
fascinating stuff actually. It originated — it was more of an
anthropologic-type study as much as anything else. Dr. Gajdusek working out in the field,
in conjunction with Dr. Gibbs here, went out to see the
Fore people in New Guinea. You pull out your map and you
look around Australia there, up there and you’ll find New
Guinea, particularly Papua New Guinea. The Fore people were there — F-O-R-E. And they had this interesting disease,
this degenerative neurologic disorder. Where they just started having all
sorts of walking like drunken sailors, shaking, and — we find — why is that? Well, they had an interesting — they
had one very interesting thing about them. When their ancestors would die,
the Fore people would consume them, through cannibalism, essentially. And they would eat their brains. And it was found — this was
a cause for the transmission. So the cannibalism
stopped, and so did kuru. We know kuru probably a bit more,
what better known as Creutzfeldt-Jakob disease; CJD for those
who are in the neuro-world. It’s actually is important because
it happens in about one in a million people. And when there’s a suspected CJD
patient that’s being biopsied, the room gets shut down, every
instrument essentially gets thrown away. It’s a big deal. But it’s become better known to us
to be as BSE — mad cow disease and specifically I said scrapie,
which is seen in sheep and rats. Sheep would go up against a fence and
scrape themselves so hard that their wool would come off. And that’s why it came known as scrapie. Now the interesting thing about this
is this an idea that maybe at this time you’re all used to. But the thought that something could be
transmitted with no evidence of nucleic acid, no DNA, no RNA,
not the way that bacteria, fungi, protozoa, viruses all
have some form of nucleic acid. And these — these did — do not. And what — it was found — is that
these are essentially proteins that seem normal to our body. They’re not — they think of them as our
normal proteins that have developed an abnormal method of folding that can
induce folding amongst other proteins. Still not fully understood, but
essentially a transmissible disease with no nucleic acid that’s still
extremely unique in the armamentarium of infectious diseases. So, so interesting, as a matter of fact,
that it’s earned at least a couple of people Nobel Prizes. And one of them indeed
was Dr. Gibbs’s partner, Dr. Gajdusek. Now these are some of my early mentors. I bring them up because it’s very
important to sort of get this started now to recognize who your mentors were. And Mentor, by the way, is
capital letters there actually. And that is a — it’s a proper word. It’s a name — just a little history. The name Mentor was actually a person,
a friend of Odysseus back in the Greek classics who took —
helped take care of his son. Not surprisingly the word has gone on to
mean that someone who is — someone who helps you, someone who
imparts knowledge to you, perhaps wisdom. Lavonne Parker [spelled phonetically] up there in the middle is
the man that [unintelligible] here was actually one of the — one
of the — he was actually the man who coordinated the summer program. Very much championed everyone
coming in and with the emphasis on underrepresented communities. He worked also closely with Dr. Gibbs. And Dr. Gibbs was
wonderful man who, really, I don’t think that I’d be anywhere
where I am right now without him and the manner which he helped me. But as time went on, I
went on to Minnesota. And that’s Fernando Torres down
there, upper left-hand corner, Rafael Tamargo, and Dr.
Costwick [spelled phonetically] over at Johns Hopkins. Just a little thing to remember him. He started out as a young biologist,
getting his bachelor’s from the University of Maryland Eastern Shore. And after becoming an administrator,
stayed on for 42 years as a director of summer programs, finding time to mentor
hundreds of students and be a U.S. Army and Air Force veteran as well. Dr. Joe Gibbs was — when I was here
— the Deputy Chief and eventually the Chief of the Laboratory of
Central Nervous Systems Studies. As I mentioned, [unintelligible] being the man who showed that CJD
was transmissible amongst — between primates, earning Dr. Gajdusek an
Nobel Prize for medicine in 1976. He himself was a very
serious man about his careers. He was a Navy captain, serving
in World War II from ’43-’46, been 40 years in the [unintelligible] ; mentored hundreds of students,
probably a bit of understatement as a matter of fact. He was very prolific that way. Dr. Torres himself took me
under his wing in Minnesota. And I worked in the EG lab for a couple
of years studying transcortical magnetic stimulation. Before MRI, before CT, there was
a time that many have forgotten. But EEG was actually
used very — great deal. And he pioneered the study of pediatric
trauma in EEG and headed up the EEG lab where I worked for my
first two years in med school. Eventually, coming back closer to home,
spent eight years in Baltimore doing my residency. And in two of those years, spent
some time doing neurovascular research fellowship with Dr. Tamargo, doing a —
working on an inflammation and stroke in rat middle cerebral
artery occlusion model. And one of the beautiful things I had
to show for two years was a miserable allergy to the rats. I — [laughter]>>David Antezana: They’re even more
painful than some of the PTSD I had from all the western blots
that we did — [laughter]>>David Antezana: — that we
did here, through all that time. So, and the one thing I did that was
a little unusual is after a period of time, I always had my peripheral vision
always kind of seemed focused on what Dr. Costwick was doing. I’d come in — as
neurosurgeons back then, we weren’t used to seeing — nowhere
on a neurosurgeon’s agenda or operative schedule would you ever
see a T4 to S1 fusion. You didn’t see that in the early ’90s. It didn’t happen. And I found myself interested, but
really there wasn’t any way to talk to him because neurosurgeons didn’t do
orthopedics spinal deformity fellowships in those days. So I made a few friends in
the orthopedic department. One of them was a wonderful
man by the name of Cam Huckell, and he went to talk to Dr. Costwick
who gruffly told me he did accept applications from neurosurgeons. He just never taken one before. And after a quick and gruff interview,
he was kind enough to take me. Because I just couldn’t bear the thought
that I would graduate without knowing how to do what seemed to
be a interesting surgery. As time went on, it was a bit unusual. I think I’m probably one of the first 10
neurosurgeons whoever did an orthopedic spinal deformity fellowship. And now it’s pretty commonplace. But it’s one of those things
where when you meet people, you find mentors, and you make sure that
you continue quote “neural-networking, or networking — the case may be. You’ll be surprised at the
opportunities that’ll open up for you, perhaps one that you
didn’t even think about. And then finally, another area that I
was interested was stereotactic radio surgery and has developed into
a practice with Gamma Knife, and thus leading me to one of
the areas that I went to discuss. Called neurosurgical hybrids because,
as you heard earlier from a wonderful discussions from the previous
— your previous speakers here, that neurosurgery in and of
itself doesn’t exist in a vacuum. No part of medicine does. But one of the things
that can happen is, for example, as a neurosurgeon, you
take a walk into the world of quote “endovascular work,” often thought of
as the area or the playground of the radiologist or cardiologist and heart;
and not only become expert in the area but become the expert. And one of the things that
hadn’t been done very much, neurosurgery and orthopedic
surgery had existed very separately. That doesn’t happen so much these days. And that really has only
been relatively recent. Not unlike the neurovascular
surgeons who are capable of doing both endovascular procedures
and the open procedures. There just aren’t very many of them. And now, because we have more
and more people who can do this, there just still aren’t a lot of us
who are a bit on the older side that had spent a lot of time
training in both areas. And what it does lead to is a hybriding. Once again, sort of cross-fertilization
of different disciplines being able to speak with each other and
coming to understand each other, where perhaps there may have
been some animosity before. And there certainly was in
the Scoliosis Research Society, which I’ll touch on later,
as walls get broken down. And it leads us to be able to spend more
time doing complex procedures with adult spinal deformities, spinal tumors
that might also lead to difficult and deforming spines which can be corrected. And finally, bring in more
neurophysiology into intraoperative neurophysiologic monitoring where
you actually can monitor somatosensory potentials, motor evoked potentials, as
well as direct stimulization of nerves, in order to be able to see and
monitor exactly what’s going on during a procedure. And see if you have to make
clinical changes surgically at the time. Additionally, finally,
there’s radiation oncology. They found that indeed they just
bought something called a Gamma Knife. Stereotactic
radiosurgery, not really surgery, per se. But what it did lead to is an
ability to work radiation oncologists. And opportunity came up to go to the
Karolinska Institute where Lars Leksell and others had worked over in Sweden
to add to this technique and learn this particular brand of it. And so I moved on to that area. So let me show you a
couple of things that we do. A 45-year-old female presented with
scoliosis during child — was diagnosed with scoliosis during childhood. Never really did much,
wasn’t particularly bad. But as time went on, it progressed. She’d failed all conservative
forms of non-operative treatment, chiropractic
treatment, physical therapy. She’d even gone off to
naturopaths [spelled phonetically] That’s very common in
Oregon, by the way. The upper Northwest, it’s just
naturopaths just everywhere. And they certainly have a
role to play, but — well, we’ll quickly just move on from that. So she presented to me with severe
progression of leg pain and significant L34 radiculopathy to
the anterior thighs. In regular English, what that means is
that the lumbar nerve roots L3 and 4, like many others, have
what we call dermatomes, areas that they govern. And the front of the thighs over here,
down to — even down to the knee and even below, can be L3 and/or L4 type
of pain when the nerves are getting squeezed or affected. And so, she presented for surgery, was
a touch of a — she was a generously proportioned lady, and so required a
little bit of weight loss before we would operate on her. So she lost 30 pounds so that we could
do what I felt best at the time was a combined anterior-posterior
approach to her spine. And so here we go. This is how she presented and this is
the lumbar curve that she had that was — this point progressing. It was contributing to her back pain. But in the adult, unlike kids, okay —
in the adult deformity population leg pain is really one of the big reasons —
and nerve root compression — why people end up having surgery and why
they have significant pain. And so by taking off the compression,
we straightened out the spine and she’s doing much better. This is what she looked like from the
side and we were able to maintain the appropriate lumbar
lordosis and thoracic kyphosis. Stereotactic radiosurgery which is
fun, because I don’t actually have to operate. I put a frame on a head;
I can have an espresso, cup of coffee, and do a
little bit of planning. But I get to work with the radiation
oncologist and physicist which also allows me once more additional
cross-fertilization to understand what someone else is thinking — their
approach to a disease process that we [unintelligible] And what it does it — stereotactic
radiosurgery sort of not unlike taking a magnifying glass on a hot
summer day, focusing it on a leaf, and burning a little hole
in there and then stopping. And surrounding areas — as the gamma
rays that come from the radioactive come through the target and then disperse. They just burn that area and this done
by placing a helmet on someone’s head, literally putting the screws
to them at four locations. We use Lidocaine, by the way, just so
you know to kind of numb the pain a bit. X, Y, Z coordinates,
it’s very straight forward. Put someone in an MRI, then
you put them in the machine, and by programming someone with
this type of apparatus on their head, you get down to submillimeter accuracy
of being able to treat some at skill base. Very simple, very straight forward
concepts that took a great deal of complex programming and
money to put into effect. And this is a bit more of a picture
of what the cobalt looks like itself; the column meters that are
used in order to treat a patient. Here some real live cases. An acoustic neuroma which is a tumor
of the skull base and cerebellopontine angle. If you draw a line straight in your
external auditory canal and one just off the midline through the same side, where
those lines intersect is where you’ll find this tumor coming
off the 8th cranial nerve. And often people
present with hearing loss, miserable tinnitus before. Almost the entire time you’d
have to undergo an open procedure, which would be quite
successful but quite painful. And very — unfortunately,
more often than we’d care to say, would leave you with
a 7th nerve deficit, meaning your face would look like this. And you wouldn’t speak very well either. Unfortunately, that could be
very significant and debilitating; no one likes looking like
that or sounding like that, do they after all? Now the thing is, if you took the
best surgeons on the planet — highly, highly skilled surgeons, then you
had them do the open procedure, oh they could get you pretty much the
same results you get with Gamma Knife. But this frank reality is means there’s
a lot more people that can get treated by those of us who may not be so
skilled at skill base perhaps. In any case, what it does
deliver is very solid results, without having to open someone’s head. They come in in the
morning; they’re gone by lunch. Something else you can do is
treat trigeminal neuralgia, facial pain that can be so severe that
people commit suicide as a result of the pain. Something that’s very well known in
neurological and neurosurgical circles. We can take these patients, and with an
approximately 80 percent success rate, treat them in the same manner without
having to perform a similar procedure as you would with the
tumor — to go in and, basically, rough up the 5th nerve and
take any vascular vessel — any vessel, any artery that may be on it causing. Triggers would include
significant talking, chewing, showering, and brushing your
teeth itself could cause this pain. People would lose significant
weight, become malnourished, and withdraw from society often
times as a result of their pain. And this is similar
treatment, a few slices up, here’s the 5th nerve, few — it’s a few
millimeters away but from where the 8th nerve would be. But for the purposes of neurosurgery,
it might as well be a mile. One of the things I’ve been able to
do, despite the fact that it’s private practice, I think one of the things
I’ve been able to do is actually, fortunately, be involved in NIH studies
here through John’s Hopkins because of the time I spent there. With spinal deformity, I’ve used some of
the work that I did with Dr. Costwick. To be able to look at some of their
complications and outcomes they were doing in a relatively burgeoning
field where complication rates, even amongst the most
competent surgeons, can be 25 to 35 percent, very severe. Finally, with Gamma Knife
we’re doing case studies. So this has been an interesting
— interesting to be able to do. I won’t focus on it much other than to
tell you that the reality is even in private practice, if you take the
time and you know take time out — yes, you have to cut out a few surgeries
and take some of your resources and pay people — like these wonderful people
that help me — that you can actually do some work. And it is fascinating and wonderful
to stay intellectually stimulated throughout your career. And every now and then you do have to
take a step back when you’ve been doing something for the same
way for a while and say, “How do I want my life to be different? How do I want things to move forward?” So there’s Jennifer on the left who’s
my assistant who makes certain that — well, basically, she runs my
life outside of the house. Christine immediately there
who’s my research assistant; and without her I wouldn’t have been
able to get any of this off the ground. And the newest member, Dr. Baker
— doctor of nurse practitioners, they have that now. I did not know that, but she applied and
she makes certain that I get back — if I’ve been a little tardy in getting back
to my patients — so they don’t want to shoot me I get to people and
has kept me on track fortunately. Finally, what is your
future going to bring? Well, for me I’ve been fortunate
enough to be admitted into the Scoliosis Research Society as an active
fellow after many years as a candidate. And we neurosurgeons are not the largest
group in there yet but we’re working on it. And as I go and involve
the team — yours — well, it can be like this. The world is your oyster; it’s a
little pearl in there or something. But you’ve heard that; I
won’t try to be too redundant. Everyone here has
told you that, you know, your life can be pretty much
anything you want it to be. They’ll — you have enough time to learn
about — well some of the limitations that life can bring and the realities. But what’s most
important really are our family, as Dr. Meeks brought
up really quite nicely, and your friends and just having
a good way of looking at life. [speaks Quechua] is Quechua. My family hails from Bolivia and our
blood background stretches back to the Incas. And this is a language I knew how to
speak when I was about 5-years-old. And I’d visit Bolivia and my parents
would let me run amuck on the farm thinking that I’d learn
Spanish from everyone around there. And they had forgotten that on the
farm, back in those days in Bolivia, no one spoke Spanish. They all spoke Quechua. So I’d come back to D.C. after the summers and I wouldn’t
want to speak English or Spanish. And two days before school started
all I wanted to do was speak Quechua. But since I’ve forgotten it. But the thing is study hard and think if
I can leave you with anything is that I remember — what is it
that gets you where you are? Well, you’re all smart. You’re all smart or
else you wouldn’t be here. One thing I learned is that — in one
ways — in this life just having a good, strong work ethic, just
being nice to people, and smiling as often as
you can, even when it hurts, has gotten me a lot further in my
life than my intellect ever has. And so remember, especially for those, I
want to bring up those — remember that you’re under represented part of the
community — and for all of you the others will start looking for you for
guidance a lot younger than you may be comfortable with it and
thus you will need wisdom. So remember who’ll be your mentors. You know, for me they were — were
people from Father Peter all the way up to John Costwick, who will be the ones
that you will look to to develop some of this wisdom that you will need to
someday be able to come back and give good advice to younger
people who want it and need it. Here’s a view from —
that we have in Portland. If you’re ever interested in coming out
to visit in Oregon I’m pleased and proud to say that we have many
views like this in Oregon. So come out any time and I can tell you
the view from the top up there is better than the — even better
than the view from below. Thank you. [applause]>>David Antezana: I hope I
didn’t run too much over.>>Rita Devine: A question. All right one quick question.>>David Antezana: Yes. Yeah.>>Female Speaker: I was
wondering what the [inaudible] — >>David Antezana: Right. So there is an ideal size actually. So tumors generally are — in
general we would prefer that tumors be 3 centimeters or
smaller in order to treat. We can treat even multiple tumors,
multiple metastatic tumors at the same time. But depending on the location, you do
have to be careful about the cumulative effects of how many
areas you’re treating. And if there are some structures —
such as the optic nerve — which are extremely sensitive can only tolerate so
much radiation and you may be limited in your ability to be able to
perform the procedure in those cases. But we are also doing
tremors even, for example, in certain situations and we certainly
treat vascular lesions as well, some vascular selected lesions. Thank you. [applause]

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