When you sit down with someone like Dr. Haring Nauta, you become acutely aware that you are in the presence of immense wisdom and experience. At 75 years old, Dr. Nauta has a lifetime training residents and doing research in the field of neurosurgery. Aside from the seemingly endless insights on leadership and training, one of the most fascinating aspects of our conversation revolved around Dr. Nauta’s work with the punctate midline myelotomy. He is likely the world’s leading expert on this procedure and I was fascinated to learn more about it.
A life-changing procedure
It’s no secret that the medical field suffers from an opioid crisis. Narcotics are widely prescribed to treat both chronic and acute pain that can’t be improved through surgical intervention. It’s a complicated issue without clear solutions that I’ve talked about previously on my podcast. One thing that exacerbated this issue was our inability to adequately decrease midline and visceral pain through ablation. This is no small issue because many cancers originate here. However, the discovery of the postsynaptic dorsal column (PSDC) pathway changed what we thought was possible for visceral pain management. It led to the development of the punctate midline myelotomy which damages the ascending fibers of the PSDC pathway to interrupt visceral pain transmission.
The operation provides life-changing relief for patients whose lives have been dominated by either pain or narcotics. The ideal candidate for this procedure is someone who is not having complications from recurrent diseases like cancer and whose life has become unmanageable from the amount of narcotics required to manage pain daily. By undergoing a punctate midline myelotomy, patients can take their life back from pain. It also allows surgeons to interrupt the visceral pain pathway without bothering ambulation or sexual function. Patients don’t have to choose between a lack of pain or being able to move and live independently.
Realistic expectations
While Dr. Nauta feels that the punctate midline myelotomy is an underused procedure, he also acknowledges the hurdles that come with it. Convincing patients to have an open operation on patients when they have cancer and likely just had surgery is no small task. Aside from potential health risks, many cancer patients don’t want another surgery. It’s too much stress on their mind and their body. As Dr. Nauta put it, “Some people are just okay taking narcotics for pain.” The punctate midline myelotomy is mainly for that niche group of neurosurgical pain patients who are looking for long-term solutions without narcotics.
The recovery time from a punctate midline myelotomy can be anywhere from three days to a week-long hospital stay before there is enough pain control to just manage with oral anesthetics. After surgery, pain is initially confusing because patients can’t differentiate between the visceral pain they’re used to and post-op pain. Dr. Nauta recalls a moment when patients wonder if the procedure worked at all. However, as the operative pain goes away, they realize their original debilitating pain is gone. And at that point, they’re usually quite happy. More research is needed for future applications of this procedure, but I believe the future is altogether bright with Dr. Nauta leading the way and training the next generation.