Traditions have been the bliss and bane of humankind… Change is very difficult for most and when faced with change we fight tooth and nail because change probably brought more bad than good and this is what is imprinted in our genetic memory. Comfort zone is a place with no change at all..It is the best fucking prison that everybody wants to be in.

In my view, trauma surgery was looked down upon by everyone because it is really simple and there was nothing interesting except for the residents to see brain although it was a mess… Residents did trauma all over the world. It was like a fucking training in seeing the brain and having a license to do pretty much whatever one would want to do. There were hardly any seniors who would come to do head trauma… And the so called bigwig trauma surgeons who made policies and talked about P values and multi billion dollar studies hardly operated on trauma… They were mostly data collectors, the data from the fucked up non microsurgical surgeries that the residents did..It was win win for the seniors who did not want to lose sleep at midnight, the residents who wanted some training, the industry who wanted to put implants for the bone flaps thrown away, the journals and the P value kings who were supported by industries and the only losers were the patients and the innocence of most naive neurosurgeons, who sweared by articles in these journals written by the P value kings and data collectors from the comfort of their rooms…

Many of the senior Neurosurgeons tried to be dismissive by letting me know that “I don’t do trauma, my residents do that or I have better things to do” or “Why would you ever think of using Microscope in trauma?”, “My Elective cases are more important and I need my elective theatre ready by 8 in the morning” …and so on… So, I decided to make sure trauma surgery would become one of the most complex surgeries that anyone can ever think of… You see, I love complexity.

I started to study the problem of opening cisterns in a tight brain. The cisterns are located in the base of the brain and any attempt to reach them with the standard surgery would result in brain coming out like toothpaste… I gathered that the brain was folded in two ways and one would need to unfold the brain to reach the base… The ways to unfold the brain was to drill the bone away at the base (Sagittal unfolding or unlocking) and also peeling the temporal lobe away from the cavernous sinus to create space between the medial temporal lobe and the opticocarotid complex(axial unfolding or unlocking) and of course intradural Sylvian dissection (I called it the oblique intradural unfolding or unlocking).

The manoeuvres that one would need to do to effect this unlocking would include sphenoid ridge drilling, anterior clinoidectomy, transcavernous dissection, sometimes posterior clinoidectomy and in the intradural phase opening of the membrane of Liliequist, all in a really angry brain… Suddenly trauma surgery became the most technically challenging microscopic surgery… from decompressive Hemicraniectomy which could be done probably by a cow operating an earth mover.

The results were miraculous and in many meetings that I presented my work, people implied that I was either lying or mad… Some even said the Preoperative scans and the postop scans, I showed were of different patients. Many tried to ignore me and the procedure. Most of the data kings and their minions were dismissive and abrasive and some even tried to threaten me of dire consequences. Some kind souls advised me to get out of this as I was doing good skullbase and vascular work and they told me to focus on that and leave this..But none of them had any idea of how stubborn I was, or how “passionate” (read fucking Mad) I was… I had seen the truth and I would somehow go up against everything to prove it…

I found a lot of support as well during this time coming from the most unlikely quarters.. from the UK and from China and Japan.. Nick and Yi were brothers and Professor Kato was my teacher… Nick and Yi were excellent surgeons.. and both started doing the procedures and they understood what the procedure meant. Prof Kato was a master surgeon and the president of the Asian Congress of Neurological Surgeons and she understood the implications and encouraged me to work hard to bring out the truth.. She asked many of the organisers to include my presentations and many did comply…

My first formal lecture on Cisternostomy was in Baoding, near Beijing circa 2011… a huge department with over 22 professors and over 100 staff… almost all of them in attendance and with Yi translating for me… For the first time, I saw interest in many eyes instead of contempt.

Now as others started duplicating the results, we had to figure how the surgery works, and what is the science behind it. I started thinking hard and looking hard for clues in the scans as well as in clinical signs and the research done so far… and figured that the hundred plus millilitres of water or CSF in the base of the brain just vanished as early as just two hours after head trauma on the CT scans, the technical term for that being absent cisterns.. And the brain was swollen…

Any child or even a Med student who is not damaged or biased by the so called education, would tell you that the CSF at the base of the brain went into the brain and that is why the brain was swollen and the CSF was not seen.. Not the data collecting Trauma Neurosurgeons though… Most of those guys told me that the CSF was compressed by the swollen brain!! And some told me the water went into the spinal canal… Both are impossibilities if one knew a little elementary Physics. A hundred millilitres of CSF getting compressed to nothing would generate impossible pressures and would need an elephant to stand on the brain something like that… and the same would be true in the spinal canal as well… Imagine trying to inject half a glass of saline into a 2 Litre Coke bottle…

I wished the 100 ml actually went into the spinal canal..If that was the case, the spinal pressures would have gone up and good old Theodore Kocher would not have come to a conclusion in head trauma that started Decompressive hemicraniectomies. You see, he said… “When there are clinical signs of raised intracranial pressure and the CSF pressure is not high (the guy stuck a needle into the spine and measured the CSF pressure and saw that it was normal or near normal… Something that we would anticipate in head trauma) then, we must decompress the brain by taking off the bone and opening the dura wide”… 100 years of fucking wrong surgery based on a wrong observation… And still going on because of different reasons altogether…

Sometimes, traditions were right for the certain period thousands or hundreds of years ago and we should outgrow them as we know better… like the concept of marriage for example. The most and the omnipresent industry of prostitution would never have survived if there was no marriage… And we could say the same for many of the Medical industries as well… Imagine the third world spending billions of dollars for titanium plates manufactured by Industrial giants based in the west for the patients whose bone was removed (the most common surgery in most trauma units in the developing world… which was almost five sixths of the world’s population). These industries support and fund most trauma conferences and probably the studies trying to revive a dead and mummified decompressive hemicraniectomy with selective usage of P values in some of the most hallowed journals whose pages are what the scientific folk swear by… and this unholy nexus is a bit more dangerous than marriage and prostitution bit, I would think.