WORKING ON THE FRONT LINES
of Neurosurgery

Two years ago, William Monacci, M.D. was playing a pivotal role in the care of soldiers wounded in Iraq, and the experience is never far from his mind as he continues his career in neurosurgery here in the Lancaster area.

For five years before joining Lancaster NeuroScience and Spine Associates, Dr. Monacci held the rank of Colonel, and served as Neurosurgery Consultant to the Army Surgeon General. He was then Chief of Cranial Base Surgery at Walter Reed Army Medical Center, where he was involved with the deployment of doctors to the military hospital in Landstuhl, Germany. He also worked treating soldiers with critical head injuries from roadside bombs in Iraq.

Dr. Monacci knows firsthand one of the paradoxes of war -- that combat provides medical teams with increased knowledge about blast injuries and how bruises to the brain can affect the central nervous system. Shrapnel wounds, Dr. Monacci observes, often inflict vascular damage, referred to as pseudo-aneurysms, and the expanded incidence of treating them has also advanced medical science.

Television has brought the complexities and range of those injuries into American homes, most dramatically when ABC's co-anchor Bob Woodruff was badly wounded in Iraq in January, 2006. "Our armed forces, and the journalists who cover them, are getting the kind of sophisticated surgical care unavailable in previous conflicts," Dr. Monacci said.

He notes that there are many US neurosurgeons who have done voluntary work in the war to support their country and ease the burden of the 16 neurosurgeons presently on military duty. He points out that with a population of 160,000 members of the armed forces "doing everything they could be doing over there," there is the same need for neurosurgical care as there would be in the normal population. Motor vehicle accidents, people falling, ruptured discs, and brain tumors happen in a war zone too, adding to the list of medical procedures required on a regular basis.

Dr. Monacci has experienced firsthand the techniques that were first used in battle zones and then became standards of practice on the home front. One such tool played a role in Bob Woodruff's recovery. Known as the LICOX® brain tissue oxygen system, it monitors the level of oxygen in brain tissue and reveals how surgeons can best optimize the brain's environment to prevent secondary injury.

Each year in this country, 1.4 million individuals sustain a traumatic brain injury (TBI), a head injury that disrupts the brain's normal function. The initial trauma is just the beginning. The challenge for the medical team is to prevent secondary injury, when the brain reacts to the event. The brain is 80 % brain tissue, 10 percent cerebrospinal fluid, and 10% blood. After the injury, swelling increases intracranial pressure, blood flow decreases, and secondary injury results.

"We started using The LICOX® system at Walter Reed and Bethesda Naval Hospital in 2004, Dr. Monacci explained, "and the same oxygenation system was recently implemented at Lancaster General Hospital. The next time we get a patient with a severe TBI, the system is in place for advanced brain monitoring," he pointed out.

Experience with veterans here

Dr. Monacci sees a lot of veterans through the Lebanon and Coatesville VA Medical Centers. His experience here affirms his faith in veterans' access to the appropriate health care, and that, he says, means that the V.A. is in step with improving technology in cranial and spinal surgery.

"It's gratifying to see veterans get the care they need in a timely manner," he said, "and to know that we can apply advances to them as readily as to anyone else." New spinal hardware and techniques for endoscope brain surgery are revolutionizing the way surgeries are performed, he explains, allowing for less invasive procedures, and thus faster recovery.

Many veterans come to see Dr. Monacci because of degenerative changes in the spine, which along with cranial surgery is his area of expertise. As with the general patient population, surgery is a last resort. "Our function is not just to operate, but also to diagnose, and find the best path for pain relief and restored mobility, surgically or otherwise," he said.

He acknowledges that he misses his friends in the military, but he keeps up with them through the Internet and CNN. He enjoys the common ground he shares with Pennsylvania veterans who appreciate his experience, and at this stage in his career, he's glad for the opportunity to treat patients with a wide variety of complex spinal and cranial problems. The chance to make a difference in a patient's quality of life is the force that continues to drive him.

Bright future for neurosurgery

Dr. Monacci describes neurosurgery as "still in its early stages despite its present level of technical sophistication," saying "The future is going to bring more applications of neurosurgery to health care."

"We are getting better at determining the origin of pain in a patient with a particular spinal disorder and developing less destructive methods for treating brain disorders," he said. "Tumors that were once thought untreatable are having increasingly successful outcomes. We have at our disposal locally the latest in technical innovations to apply to our patients' problems," he continued. "The ability to treat serious spinal and cranial problems here in Central Pennsylvania is on par with any major medical center in the country."

The surgeons and physiatrists of Lancaster NeuroScience & Spine Associates diligently keep up with technology, he says. And he added that they keep their perspective about the latest innovations trumpeted on the news and the Internet. "Just because there is a new technique or device, it doesn't make it the gold standard," he said. "It may not be applicable to every patient. It's our job to find the segment of the patient population that will benefit from it," he concluded.

"I chose neurosurgery because of the broad spectrum of problems that patients face, and the variety of ways that I can help them," he said. "The nervous system is the most complicated and most elegant system in the body, and having the potential to impact it in a positive way is totally gratifying."
-- William Monacci, M.D.