You could easily say that Sandi Wearing's ability to speak — and she
is as forthright as a 67-year-old can be — was saved by a football
game and two Stanford Hospital doctors who weren’t afraid to try a
surgery whose rarity belied its impeccable logic.
a routine test, Wearing's local doctors had found a mass at the very
top of her spinal column, where the brain stem, the body's
neurological headquarters, begins its climb into the skull. That
mystery lesion, they thought, might be what was causing Wearing's
tongue to be crooked and to weaken her arms. Something was pressing on
the nerves to her tongue and her arms. Once Wearing arrived at
Stanford, she found two physician-scientists, Stefan Mindea,
MD, and Jayakar Nayak,
MD, PhD, who would save her speech with a surgical procedure
that reached her spine through her sinuses. Never before done at
Stanford, the endonasal odontoidectomy has probably been done fewer
than three dozen times worldwide. There are just a handful of medical
centers anywhere that can accomplish this level of endonasal
"My husband and I decided we just couldn't
let things get worse, that no good would come out of waiting,"
Wearing said. "I'm a pretty pragmatic person; you'll never see me
agonizing over a paint color."
On the day of her
procedure, twenty-five other physicians were in the OR's version of
bleacher seats a live video feed projected on externally visible
monitors. "It turns out a lot of our colleagues had heard about
it," Nayak said, "and were asking 'What the heck are you
Surgery of any kind near the brain
stem carries precipitous risks of damage with catastrophic
consequences. Traditionally, neurosurgeons have taken their
instruments to that area only through the mouth or the side of the
neck, although both procedures risk adverse effects on swallowing,
breathing and speech and require a long recovery. Surgery on the
frontal side of the spine has traditionally been done through the
mouth, too, with longer recovery, more post-operative pain and
increased risk of adverse effects.
At Stanford, however,
endonasal surgery is thriving, with collaborations between several
departments and programs. Stefan Mindea, who arrived in 2008, has been
working to advance the development of new treatments for spinal tumors
and metastases from other cancers. A clinical assistant professor of
neurosurgery, he directs the Neurosurgery
Department's Minimally Invasive Spinal Surgery program and
co-directs the Spinal Oncology Surgery program. "Because I know
what a difference a minimally invasive approach can mean to a
patient," Mindea said, "my goal is to incorporate such
techniques for as many spinal disorder treatments as possible, for
people who've been told their tumors can't be removed and for cancer
patients, whose bodies have been bombarded with all sorts of
medications and radiation. For them, a much smaller incision has a
better chance to heal quickly and that means a faster return to full
activity." Nayak, an assistant professor with the Stanford
Sinus Center, brings special advanced training in surgeries
through and inside the nasal cavity and sinuses. He arrived at
Nose and Throat Department in 2009. He joined
internationally-known endoscopic skull base surgeon, Peter Hwang,
MD, Rhinology and Sinus Surgery Division Chief. He and Nayak are
co-directors of Stanford's Sinus Center.
Wearing's, and those that go through the sinus to the eye and the
brain, have only been possible in the last decade or so, with new
imaging technologies and new, extended surgical tools which were made
to be more flexible, optically sharper and very, very much smaller.
The advantage of any such transnasal approach is that "for the
right patient, you can get to a site of interest with much less pain
and dissection through normal tissues," Nayak said. "For the
patient, this can translate to going home sooner and with much less
pain and possibility of issues that go along with more traditional
But serendipity also plays a big part in
Wearing's story. Mindea and Nayak didn't know each other until they
met by accident in a faculty lounge one evening, both awaiting the
start of surgeries. They started talking about the football game on
television and soon moved to other topics. Mindea, as it happened, had
read the paper Nayak wrote about the work transnasal spine work he'd
done with key figures in transnasal surgery before he came to
Stanford. "I had no idea that Stanford brought you here,"
Mindea told Nayak. He started talking about the challenge of a patient
like Wearing and shared his frustration with the transoral route to
"There's got to be a better way to do
this," he told Nayak. When Nayak said, with great enthusiasm,
"I can get you there," Mindea realized he'd finally found a
partner to conduct a safer, more direct route to restore Wearing's
speech and remove the mass. The surgery's official name: endonasal
odontoidectomy. Very recent technology and techniques in endonasal
surgery, Nayak said, made Wearing's surgery possible, "and, my
meeting with Dr. Mindea."
Using extra-long tools,
Nayak followed the landmark clivus bone through Wearing's sinus about
12 centimeters from the nostril margins, until he neared her skull
base and the first spinal vertebrae, C1. Then, Mindea took the lead.
"I'm not an expert at where the vertebral arteries are like
Stefan," said Nayak, "and those are important for blood
supply to the brain." All along the way, the optical scopes were
being washed with automated irrigators to keep the view clear.
Extended ultrasonic aspirators were rapidly vibrating diseased bone
and soft tissues to be removed at such high frequency it disintegrated
and was easily suctioned up.
"I remember being on
the table," Wearing said. "When I came to, there were
several doctors standing around and shaking each other's hands."
She knew her surgery had gone well, and she had much better sense of
just what surgical artistry had been accomplished. She went home after
just three days, walking comfortably, and barely using pain
medications, but Nayak and Mindea forbade her to go on a scheduled
camping trip. "You are our prize patient," she said they
And shes again speaking freely.