FROM SILOS TO SYNERGY
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axonal injury of the upper trunk of right brachial plexus with no evidence of reinnervation. The prevailing surgical approach in such cases was to use sural nerve grafts to bypass the site of nerve injury. Dr. B was concerned about the uncertain prognosis for recovery of function after the procedure. The reason for poor prognosis after sural nerve graft in some of the patients was unclear, but additional injury causing nerve root disruption was one theory. It was difficult to confirm or rule out such additional injury by EMG in the presence of a more distal injury. Note that it was the pre-MRI era and hence documentation of a pseudo meningocele in the MRI, an easy way to confirm nerve root disruption, was not available. At my suggestion, after exposure of the brachial plexus in the OR, electrical stimulation of the components of the plexus proximal to the injury was done, and I recorded the evoked signal over the cervical spine and the scalp with subdermal needle electrodes. The signals were good, indicating intact conduction in the nerve roots. The plexus was repaired with sural nerve grafts and the patient noted significant improvement by three months. The care of this patient is thus an example of collaborative effort between the surgeon and the neurologist that benefited the patient. My collaboration with Dr. B expanded over the next several years and I was proud to be part of his team( assessing nerve function by EMG prior to and serially after the transplant), which performed the first successful hand transplant in the U. S. at Jewish Hospital in Louisville.
Patient 2: A 30-year-old woman had been experiencing drug-resistant convulsive seizures with an aura of a strange smell. The patient was getting depressed and suicidal and the family felt that she was not receiving optimal medical care.
Let me explain the circumstances in which I saw this patient. I was asked to direct the epilepsy clinic and the EEG lab at the University hospital, about four decades ago after the departure of a senior faculty member. Epilepsy was an area of great interest to me as I wanted to organize a larger seizure monitoring facility and initiate a fellowship training program in clinical neurophysiology, which came to fruition after a couple of years. These developments were crucial as epilepsy surgery and neuromodulation techniques such as vagal nerve stimulation needed pre-procedure detailed evaluation at the seizure monitoring facility. Surgical resection of the epileptic focus is a procedure that needs close collaboration between the neurologist, neurosurgeon and the anesthesiologist. In Louisville, neurosurgeons under the leadership of Dr. Henry Garretson collaborated in this venture and were able to treat several patients with drug-resistant epilepsy. Seizure monitoring in patient 2 showed an epileptic focus at the right anterior temporal lobe. MRI did not show any structural abnormality. After exposure of the brain, electrocorticography, interpreted by the neurologist, confirmed the location of the seizure focus. The anesthesiologist woke up the patient and functional cortical stimulation was performed to ensure that the seizure focus could be resected without causing major loss of function.
Following the surgery the patient remained seizure-free and was able to pursue gainful employment(“ I got a new life!” as per the patient). The desirable outcome can certainly be attributed to collaborative medical care by multiple specialists.
Patient 3: a 15-year-old with increasing scoliosis leading to thoracic and lumbar pain. This patient was evaluated in the late 1980s during which spine surgery was becoming safer with new techniques and procedures. Dr. Kenton Leatherman of Louisville( Norton Leatherman Spine Center) was a pioneer in scoliosis surgery and is credited with the first surgical repair of scoliosis; he pioneered the use of Harrington rods. Dr. Rolando Puno, also from the Leatherman Spine Center, developed the world’ s first polyaxial pedicle screw in the 1980s. With increasing number of surgical procedures for scoliosis, the very rare complication of spinal cord injury was recognized, which can potentially be devastating to the patient. Early 1980s saw the development of somatosensory evoked potential( SSEP) monitoring, which could alert the surgeon promptly if spinal cord function were being compromised during spine surgery. As a neurologist using SSEP for diagnostic purposes, it was exciting for me to collaborate in that venture. Our patient underwent Harrington rod placement; at a certain stage of straightening of the spine, the SSEP deteriorated and the surgeon was alerted. He was able to modify the process and the SSEP eventually became normal. Everyone was relieved when we realized that the patient had no signs of spinal cord injury after the procedure. Again, this was a fine example of collaborative effort by neurologists, spine surgeons and anesthesiologists with better outcomes for the patient.
There are numerous other situations where close collaboration between the neurologist and surgical colleagues( neurosurgery, orthopedic surgery, hand surgery) is crucial in achieving the best outcome for the patient. Modern management of stroke is a perfect example of team care involving the emergency care physician, neurologist, neurosurgeon and radiologist, in addition to other healthcare professionals. Dementia care is a situation where teamwork models do much better than single profession medical models. 3 Let me wind up with an apt quote from Helen Keller, who is an inspiration and hope for anyone with disability.
“ Alone we can do so little; together we can do so much.”
References
1
Anyaegbu EH et al. Patient and physician narratives on collaborative care between emergency and family medicine services: A narrative review. Cureus. 2025; 17( 11): e98099.
2
Sabapathy SR. Robert D. Acland-The microsurgery pioneer-A personal reflection. Indian J Plast Surg. 2025; 558( 6): 406-414
3
Eaton CT et al. A scoping review of interprofessional implementation approaches in dementia care for patients and caregivers. J of Interprofessional Care, 1-12. https:// doi. org / 10.1080 / 13561820.2026.2680056
Dr. Iyer practices at the Neurodiagnostic Center of Louisville and is a retired professor of neurology at the University of Louisville School of Medicine.
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