Back From the Dead15 years, 7 months ago
Posted on Oct 04, 2006, 3 p.m.
By Bill Freeman
Cooper may be without honor in his own home, but mention his name at the Fujita Health University Hospital, just outside the industrial city of Nagoya, Japan, and surgeons light up with recognition. He's been there a few times, collaborated with them on a book chapter, and told them about Candice Ivey and his other patients. They're glad to have a fellow traveler in the US, but they're quick to point out
Cooper may be without honor in his own home, but mention his name at the Fujita Health University Hospital, just outside the industrial city of Nagoya, Japan, and surgeons light up with recognition. He's been there a few times, collaborated with them on a book chapter, and told them about Candice Ivey and his other patients. They're glad to have a fellow traveler in the US, but they're quick to point out – politely, of course – that they've been doing this work longer than Cooper and have treated many more patients.
The Japanese also use a more spectacular method: They implant the electrodes right into the spine. That's what Isao Morita is doing today. Trained at the Cleveland Clinic, he's a neurosurgeon who wears his hair in a brush cut and speaks passable English. The patient, Katsutomo Miura, lies facedown on the table. He's anesthetized, even though he was already unconscious when he was passed through the doors separating the sterile surgical wing from the rest of the hospital. He's been unconscious for nearly eight years. He was 23 when an ambulance crew found him bleeding and unresponsive on the road near his home in Osaka, next to his wrecked motorbike and his helmet. His legs were shattered, and one of them is now permanently bent at the knee, like he was frozen in place as he was about to run away. It sticks up from the table, making a little pup tent of the blue surgical drapes.
"Yoroshiku onegai shimasu" ("Thank you in advance for your cooperation"), Morita says, and waits for the five-person surgical team to respond in kind before he slices into Miura's neck. It takes 20 minutes of cutting and cauterizing, of spreading muscle and clearing away blood and gristle, for Morita to burrow down to Miura's spine. "C-5," he announces to me, a little triumphantly, as he points into the cavity he has created. Peering over his shoulder, I can see the vertebra that was his target. It is pure white and glistening. Morita takes a pneumatic drill and tunnels along the spine, toward Miura's head, explaining that, so far, this is exactly how a disc surgery would go. I resolve to take better care of my back.
Morita tries to thrust an inch-and-a-half-long, quarter-inch-wide flat metal bar into the tunnel, but it won't go. He drills and pushes four more times until the electrode finally settles into place along the second and third cervical vertebrae. He snakes a wire from there under Miura's skin to a second incision he has made between the shoulder blades. Meanwhile, another doctor has been working at Miura's waist to create an internal pouch for the battery pack that will power the electrode on his spine. Now she runs a wire up to the opening in his back, and Morita, using four tiny screws, splices it to the lead to complete the circuit. Once the swelling goes down and they switch the implant on, it will send a train of electrical pulses through his spinal column and into his brain. The hard part over, the surgeons begin to chat easily as they close up Miura, even laughing a little bit about the anesthesiologist, who has dozed off at his station.
I've already seen this kind of operation. It was part of the PowerPoint presentation I got the day before from Tetsuo Kanno, Morita's mentor and the originator of the surgery. Kanno discovered the virtues of the dorsal column implant accidentally, he says, when he was using it to stimulate muscles in stroke patients. He shows me statistics on the 149 people he and his staff have treated. He cites one study of patients who had been unconscious for an average of 19 months. A vegetative state is considered permanent after one year, but 42 percent of Kanno's patients showed significant improvement. He explains that even a guy like Miura stands a chance. If the electric current keeps flowing into his brain for long enough, maybe years, Miura is likely to make "some recovery."
Which is either good news or bad news, depending on how you feel about Kanno's definition of recovery. Most of the implant recipients, he says, move up a notch in their level of consciousness, from a persistent vegetative state to a "minimally conscious state," a condition in which people are able to muster small but unmistakable signs of awareness. "Maybe the patient just smiles or follows with their eyes," Kanno says. Other Japanese doctors using deep brain stimulation – in which electrodes are implanted directly in brain tissue – have reported similar results: patients who improve to the point where they are severely disabled rather than entirely unresponsive.
But this is enough for Mariko Miura, who spent $30,000 on her son's implant. The day after the surgery, she declares through a translator that she senses her son is calm and comfortable. "If he could just show what he feels," she adds, "yes or no, maybe blinking once or twice, maybe holding hands, maybe a smile, that would be great." The doctors say this is exactly their goal, even though the patient's MRI shows that the right hemisphere of his brain is almost entirely atrophied. "There is no medical indication in this case," Morita says. "This surgery is socially indicated. It is the family's decision if they want to go on, and our job to do what they wish."
These doctors know how strange this kind of reasoning sounds to American ears. "US doctors say that it doesn't mean anything. But even if the patients can't talk," Kanno says, "if they just look up when the family comes in the room, it makes the family very happy." Then again, he says, "you are very dry people in America, dry and cool. Here we are very wet and warm. You see just a body; you say, OK, stop feeding it. But we think a person in a vegetative state has a soul."
No one is sure exactly why electrical stimulation works, but there is strong evidence that it has undefined but profound effects on the brain. We know that electricity can rouse unconscious animals and that deep brain stimulation is widely used to treat Parkinson's disease and dystonia, a disorder in which muscles twist and contract uncontrollably. Kanno and his team have also recorded that patients receiving stimulation have higher levels of dopamine and norepinephrine, as well as increased blood flow in the brain – both conditions are associated with arousal. This increased activity could well lead to nerve cells in the brain forming new connections more quickly, which a recent paper in The Journal of Clinical Investigation showed can lead to minimally conscious patients reawakening.