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'I don't mind...I love New York'

It is widely accepted that surgery of any description poses a degree of risk. This might relate to an unsuccessful transplant, a misguided injection of botox, or damage to neurologic structures that contribute to debilitating injury during a routine microdiscectomy. Clinicians spend their entire careers working with their surgical teams to mitigate the risk of injury to patients, and in some circumstances in neurosurgery, vascular surgery and orthopaedic surgery this might involve neural monitoring. Very rarely, however, would a neurosurgeon also be a fellowship-trained neurophysiologist.

Professor Francesco Sala is the Chair of Neurosurgery at the University of Verona (Italy), co-founder and past-President of the International Society of Intraoperative Neurophysiology (ISIN), and was the first to be appointed as Chair of the Neuromonitoring Committee of the World Federation of Neurosurgical Societies (WFNS). Prof Sala has also held board member appointments with the European Association of Neurosurgical Societies and the Italian Neurosurgical Society. Today, he is recognised as an advocate for neural monitoring in neurosurgery, with a high volume of peer-reviewed literature to boot. Having established an intraoperative neurophysiology unit in the 1990’s, Prof Sala’s unconventional career pathway positions him as a paediatric neurosurgeon and neurophysiologist, with parallels to his entry into medical school.

“I was born in Vicenza, which is a small town between Venice and Verona, basically. We’re very famous for our architecture, you may have heard of Andrea Palladio, one of the biggest architects of the renaissance. Typically from Vincenza we were supposed to go to Padua, one of the most famous and traditional medical schools in the country, which at that time was very overcrowded with students. And the medical school in Verona had just started, in 1986, so there were just a few students here, very quiet, very easy to get access to the clinics and talk with your professors and supervisors. So I did a quite unusual choice to go to Verona rather than Padua, that was very nice actually…I didn’t regret that.” This would be the first of a series of synchronicities that resulted in his less-than-conventional neurosurgical training pathway.

Verona is famous for being the setting of William Shakespeare’s Romeo and Juliet, but is also one of the main tourist destinations in northern Italy thanks to its artistic heritage. Indeed, at the turn of the century UNESCO declared the city a World Heritage Site because of its urban structure and architecture. Parts of the city of Vicenza are also similarly recognised. “I still consider myself from Vincenza, but actually living in Verona now for such a long time, this is my base. And I’ve always worked here, apart from the four years I spent abroad. I’ve never moved out from Verona.”

Sala recalls his interest in medicine relating to his grandfather. “My grandpa was a family doctor. He was born at the beginning of the last century, so that was a different kind of medicine at the time. The family doctor was the one that was taking care of sick people, but it was like the priest – a little bit – in the small town, where he was called by the family whenever there was a problem, if husband or wife were fighting, sometimes they would call in the doctor, or the high society family, when the lady was depressed or had some psychological issue, they were calling the doctor. It was this old-type family doctor. So I had these memories, these stories in the family”. The catalyst for his interest in medicine, however, was linked the circulatory system of small fish. “When you finish the elementary school in Italy, you are supposed to provide a little sort of – of course you are a ten year old – but it’s like a small research paper. And I remember, I did that on the circulation in fish (laughs). I don’t know why. So I did my research, we didn’t have internet at the time, so I was looking up books and cutting and pasting pictures, and I still remember this picture of the blood circulation in fish, and that was my degree from the elementary school. There was some interest in physiology and science around that time, which matured over time.”

It was again an unconventional request that contributed to Sala’s introduction to the operating room towards the end of high school. “I had an uncle on my father’s side who was a professor of surgery at the University of Padua, who had just retired, but he was still the head of the residency program there. He was going to this small hospital outside Padua to do this surgery, and he asked me if I was willing to visit him and record his surgery for his students. I was at the last year of my high school and was starting to be interested in medicine. I went three or four times with him to tape all these surgeries. I was climbing these stairs in the OR, and with this 7kg VHS tape recorder trying to film the thoracic surgery, which was very, very low-tech recording surgical videos. This was thirty years ago, almost, and that was fascinating. That was the first time I was entering an operating room and the first time I was seeing the surgery live.”

From there Sala considered medicine as a tertiary undertaking, with surgery as a distinct possibility. Having visited the neurology department for a number of months he observed the investigation of chronic disease such as Parkinson’s, Alzheimer’s and Multiple Sclerosis. An opportunity arose to undertake an exchange within the European medical community; “You could go for one month to Germany, the UK or France, and somebody then was coming to Italy. And so I did this for three years in a row, for my fourth, fifth and sixth years of medical school. So I went to Gratz, to Austria, in the general surgery department first, then twice to neurosurgery in Vienna, which was a big neurosurgical department, and also in Germany. I had a big opportunity to look at neurosurgery during medical school, and I just loved it. I said ‘this is what I want to do’. In Vienna they had this huge department…that was the first time I saw a brain, alive, in the operating theatre. So I scrubbed in for this brain surgery just to end it, of course.”

“At that time they also had a very challenging surgical procedure there; to separate conjoined twins. These were twins conjoined by the head. They had this very complicated surgery, which was on the news every day, about the twins, a lot of excitement. They were sent to North America to do some investigation, then they came back to Austria, so that was quite exciting.” The twins, Hassan and Salem, were Libyan-born that had undergone multi-stage surgical procedures concluding with the anastomosis of a common artery that supplied blood to the brains of both, and survived[1]. “Then I thought this was the best way to combine neuroscience and surgery; I like the idea that in neurosurgery you have – of course – many things you cannot treat and cure, but many others that you can, actually. So it gave me the impression that it was better chance to have something…to see the results of what you’re doing. I also like the idea that you have to make quick decisions when you have urgent cases to address, so the idea is that you have to educate yourself to make decisions in a short time, and to be proactive. That was also one of the characteristics of the discipline that I liked very much.”

Sala eventually returned to Verona do undertake his residency, working under Professor Albino Bricolo. As head of the neurosurgery department at Borgo Trento hospital for thirty years, Bricolo was considered one of the luminaries of Italian neurosurgery and the so-called ‘Veronese school’, and was the recipient of the World Federation of Neurosurgery’s medal of honour in 2013. “When I was a resident I did my rotation in paediatric neurosurgery, and during the first year of my residency, my boss at that time Professor Bricolo proposed that I go to New York City and spend one and a half years there doing research. I think it’s important for you to do research, because basic research opens your mind and gives a different attitude to neurosurgery as well. Neurosurgery is not just cutting and sewing…much more than that. And he said that basic science research is one opportunity to improve your mind as a scientist, not just as a surgeon.”

“That was the first time I took an aeroplane. I was 27 years old, it was 1994, I took the first aeroplane – because in Europe we were always driving or via train – and I’d never been overseas until then. I took this plane from Milano, which was supposed to be the second biggest airport in Italy. And I landed at JFK airport. You could imagine the impression like the small boy going from the countryside to the big town (laughs). I did 18 months of research on spinal cord injury in New York, at New York University with Dr Wise Young, who at that time was one of the ‘gurus’ on spinal cord injury research, and is still one of the most outstanding scientists in this field. So when I was there, I was talking to him, and he said ‘well if you’re interested in paediatric neurosurgery you should then take some time from the lab and go and visit Dr Fred Epstein, who is the paediatric neurosurgeon here at NYU and is one of the best most outstanding paediatric neurosurgeon’s worldwide. I started to obtain the morning rounds in paediatric surgery at NYU and also time to time when I had time spare from the lab, go into the OR.”

Dr Fred Epstein was a world-renowned neurosurgeon well-known for his unconventional surgical approaches that lead to breakthroughs in the treatment of spinal and brainstem tumours in children. He became similarly famous for offering to operate on a dog’s spinal cord in exchange for a substantial donation from the owners that would permit a young child to have life-saving spinal tumour surgery. As the story goes, Dr Epstein took his own surgical instruments to an animal medical centre and carefully removed scar tissue that had developed between the spinal cord and the dura, and Tucket the dog lived for another five years. The child’s procedure was successfully performed a week later.

Prof Vedran Deletis also worked with Dr Epstein, and served as the head of the intraoperative neurophysiology department. Deletis is also a co-founder of ISIN, and has published a high volume of literature relating to IONM, particularly relating to motor systems. “I remember, as it would be today, the first time I entered the operating theatre at NYU. They were doing probably a tethered cord or maybe a spinal cord tumour. And I saw this small child with dozens of wires coming out from everywhere – from his head, his legs – everywhere. I thought ‘wow, what is that?’. That was the first time I met Dr Vedran Deletis. He was working with Fred Epstein, and it was the first time I’d heard about neural monitoring. There was another fellow at that time, Chikashi Fukaya, who was a fellow from Japan. So I spent some time with him that morning in the OR and he showed me the potentials they were doing, and I said ‘wow, that’s fascinating’. But mostly, you know, I was interested in paediatric neurosurgery, and when I went back from New York I said ‘that’s what I want to do’.”

With his sights set on a career in paediatric neurosurgery, Sala returned from New York City feeling energised. However Prof Bicolo had other plans. “When I came back, and after I finished my residency in 1997, one day Prof Bricolo approached me again and said ‘you know, I would rather send you to NY again’ (laughs).” However Sala wasn’t at all fazed by the invitation. “I said ‘I don’t mind, I love New York’. But actually, I did mind. I said I just visited Fred Epstein, as he was very much close to Fred Epstein, they had done some interesting paediatric spinal cord and brainstem tumours. So Fred was organising this symposium every year, and Bricolo was going there every year around winter time. Then he met Vedran Deletis and he started to see what they were doing in terms of Motor Evoked Potentials (MEPs) and mapping of the brainstem. He came back to Verona and he said ‘you know what, we should have the same technology here in Verona. We’d like you to go there, be trained, and then come back here and we will start it.”

The rest, as they say, was history. Though despite Sala’s enthusiasm towards continued opportunities in New York, he was presented with a career-related existential crisis. “I was a little bit concerned, because I already spent some time in New York doing research, I didn’t spend much time in surgery. And that meant to be away from surgery for an additional two years. As a neurosurgeon, that was not an easy decision because you see your colleagues moving forward stepwise in surgical training, and you are frozen doing something else. And then I spoke to Vedran Deletis, and he said ‘you know, this may be a unique opportunity for you, because you can learn something that will stay with you forever, and you will enjoy this as a neurosurgeon. So consider this an investment, as something that very few neurosurgeons are willing to do. This is an entirely new field which is emerging now. If you come and stay with me for eighteen months then you have the opportunity to establish this in Verona with your own lab and develop the field’. To be honest, I didn’t like neurophysiology at all – I considered it very boring when I was attending neurophysiology classes during medical school. Evoked potentials? I said ‘forget about it’ (laughs). But that was an opportunity to learn something more and do this training in Fred Epstein’s department, so that was also an opportunity to see neurosurgery every day.”

Intraoperative neurophysiology was certainly not mainstream in Italy at that time. Sala recalls that some neurosurgical centres were using Somatosensory Evoked Potentials (SSEP), and some using bipolar low frequency cortical stimulation and, in contrast, centres in New York were routinely performing multimodal monitoring in neuro-oncological procedures. The widespread and rapid adoption of neural monitoring practices in the United States contributed to the development of accreditation systems that differ widely to clinical practice in Europe and Asia Pacific regions. “Nowadays, neural monitoring is considered a standard in many centres. The problem again is that, what is the ‘standard’ in neural monitoring? Because people monitor in many different ways. Also in Italy, there are problems with the fact that monitoring. Is provided by companies, who provide their equipment and the expertise. Now, there is no clear-cut credentials for this expertise. You may have people with long-lasting experiencing and training who are absolutely independent and skilful and expert in neural monitoring, or you may have a tech who has been trained for three months, 40-50 cases, then sent into the jungle to do monitoring for themselves.”

“The main problem is the imbalance between the request and the offer. Everyone would like to have monitoring, because it’s trendy, it’s important from a medicolegal perspective, but there are actually not many professionals. Neurologists in general don’t like to do monitoring, because it means they have to spend many hours in the operating room, it’s not rewarding for them, it’s not even rewarding financially because they prefer to do EMG in private practice…neurosurgeons, as I said, I think there’s an opportunity but it takes a lot of commitment. I was lucky, I think, I don’t regret what I did at all, but it may also be risky because you may end up being labelled as a neurophysiologist and then it might be difficult to get patients to the surgical community.”

“To me probably the best thing would be to train properly an IONM technologist to a higher level and see whether or not eventually they might be able not just to record but also to interpret signals. This has been a matter of debate in many countries, and of course it’s difficult to generalise because neural monitoring by all means is the practice of medicine, I understand and respect the fact that you need to have credentials to do that. Paradoxically you may end up in the situation where you have a neural monitoring professional, who is a PhD or a technologist, who is not an MD but is fully trained and expert and is the person I would like to monitor myself if I would have surgery. Or you may have the MD, which is supposed to interpret and supervise and sign the report who has little experience. So on one side you satisfy the credentials in terms of medicolegal, but you may not have all of the expertise you need to address a case properly.”

“On the other hand – of course I’m talking about the extremes – you may have somebody who has all the experience to do the job properly, but doesn’t have the title. How to solve that? That’s very different from one country to another because the legislation is different, the credentialling is different. To me the bottom line is that whoever does this job should do it properly and should have the expertise to do it. The risk is that monitoring is becoming a big business. Many companies are now on the field to provide the service, which means equipment and expertise, and in many cases this is not the case. Every country should probably form its own solution depending on the community there, the medicolegal aspects, the medical societies also, because you have to talk to them.”

“The problem of a title not reflecting competence applies to everything. You can also have a doctor who is a doctor but is not competent. Neural monitoring being a new discipline, relatively new, it’s more complex. In Italy we have a joint guideline between the clinical neurophysiology and the neurosurgery society and the guidelines state that the person responsible for neural monitoring is the clinical neurophysiologist, or another doctor with enough expertise in the field. So if a neurosurgeon has been trained in neural monitoring they can be the responsible person. The technologist is supposed to work under the supervision, so they can acquire the signals but not interpret. From a practical standpoint, for example here in Verona, our technologist has worked with us for twenty years. I don’t have the time myself to be in the OR supervising monitoring anymore, since almost a decade. Basically the surgeon is responsible for the case and he relies on the feedback of the technologist. In our hands this has worked very well over the past twenty years. We’ve never had, except probably maybe one case, a medicolegal issue.”

“Physicians supervising a technologist. Ideally that’s what we should aim for. When this is not feasible because of the lack of professionals who are interested in doing this job I think one possibility is to extend the training of the technologist…for example in Italy to become an IONM technologist you have a three year academic degree, then you do Electroencephalography (EEG), Electromyography (EMG), neural monitoring, and you don’t need any additional accreditation for IONM. We just try to keep some of them in the OR training them for IONM and then they keep in the field. One idea could be to say take this three years to become an IONM technologist, then you do an additional 2 or 3 years kind of a ‘masters’ or something specialised in IONM. Where you’re supposed to participate and become independent in at least 400, 500, 600 cases, whatever you think is appropriate.”

“When Vedran Deletis was looking for fellows in New York twenty years ago, he never accepted anyone for less than two years. (It was a) minimum eighteen months. He said he wouldn’t feel comfortable in sending back someone to do this job by themselves if they had not completed 600-700 cases. The minimum was eighteen months to two years. Which gives you an idea of some expert in the field, what could be considered an appropriate training. When people write to me saying I would like to come to Verona for three months to do neural monitoring, I say you’re welcome to come but there is no way you can go back and do monitoring yourself. It’s a big investment, if you want to do it properly. So if you do three years as a general technologist and then two or three additional years as a master…I wonder if this might be enough to perform unsupervised IONM in the OR, with ultimately the surgeon being responsible medicolegally. Because as the surgeon, if I know the technologist who is with me in the OR is well trained, I feel more comfortable and say ‘okay, I still will be responsible, but I know that person there knows what he/she is doing’.”

“At the same time, in parallel, we should train residents in neural monitoring. Not to the point that they should perform neural monitoring themselves, but as neurosurgeons they should know a little bit about neural monitoring. Then you have surgeons who (are) more educated, they can understand what is the neural monitoring, and you have the monitoring team who have an advanced level of education. I think this may be a reasonable – it’s not ideal, ideal would be physician supervising a technologist – but it could be a reasonable”.

There is no question that intraoperative neurophysiology practices are highly divisive with regard to accreditation and regulation, though it is equally divisive when it comes to surgeons’ experiences. Recently, in an interview with the Canadian Society of Neurophysiologic Monitoring[2] Prof Sala discredited remote monitoring practices that are widespread throughout the U.S; “I think true remote monitoring, meaning an individual in Toronto monitoring a case in Ottawa, should not be allowed. Would any neurosurgeon accept “remote anaesthesia” with a machine providing all vital signs and the anaesthesiologist supervising from hundreds of miles away?”. Similarly, there are an increasing number of peer-reviewed research papers detailing retrospective series of procedures without monitoring, substantiated by the absence of evidence based medical validation. “I gave a talk last year, two years ago, at the European Congress of Neurosurgery, and in the plenary spine session there was a talk ‘neural monitoring is a waste of time’. My talk was ‘neural monitoring is a waste of time – question mark’ (laughs).” Sala references a conversation with Prof Johann Romstöck, famed for his work relating to A-train EMG in vestibular schwannoma surgery; “He said, you know, in monitoring there are believers and dis-believers, and there is no way you will convince the disbelievers. He is totally right. I jump to the same conclusion. Some people, some colleagues, it’s useless to discuss because they will not change their mind. I accept that…it’s like the no-vax, you have to accept that. Then there are those who are sceptical, where there is space for a dialogue.”

“I’ve heard for almost twenty years at congresses, talking to somebody rubbing their hands saying ‘I remember a case where SSEP didn’t change, they patient woke up and they couldn’t move. So monitoring is useless’. You say ‘okay’, and you explain why. For the older generation, they grew up in a different milieu, and you cannot expect them to easily accept what is not new anymore, it’s twenty years old neural monitoring, still. Then there are those who say ‘in my hands, it doesn’t make a difference’. For example a colleague of mine, a very excellent neurosurgeon from India, I was giving a talk about spinal cord tumours and monitoring and he said well you know I look at my data, I did it without any MEPs, SSEPs, and there is no difference. I find papers where there is really no evidence, no good scientific data, and these papers are published and cited. Here there is a problem also with reviewers, because very often people who review papers on neural monitoring are not neural monitoring experts. So you end up with publications that are very weak, both from the point of supporting or denying monitoring. There is this belief to some extent, and I accept the fact that a very skilful neurosurgeon may need neural monitoring to a lesser extent, but this is a double faced coin. Because there are some information that only monitoring can provide.”

Sala speaks without disdain for those who mightn’t appreciate a clinical investigation tool that offers him insight on a regular basis. “Two days ago I was operating on a small boy with a low grade astrocytoma, but I operated once a year ago and I had to stop surgery because all of a sudden the MEPs just disappeared. I was afraid this was caused by some vasospastic changes, some hypotension, and they were not coming back so I decided to abort the surgery and left tumour behind. He recovered very quickly, the MEP came back at the end of the surgery, and he was okay after surgery. I did the second look surgery two days ago, and I had exactly the same problem. When I was working near the vessel of the sylvian fissure, I start to have drop in the MEPs, the MEPs disappeared completely when his mean blood pressure was going below 75/80. So we started at 130/80 – perfect MEPs. Everything disappear, I asked the anaesthesiologist and he said it’s 80/40 and said it cannot be so low, he cannot tolerate that. I did all the surgery pushing the anaesthesiologist to keep the blood pressure high. It was perfectly correlating with the mean blood pressure that appears on the MEPs. We left the strip in until the very last minute of the surgery before closing of the dura and I asked them to wake up the boy immediately to avoid any hypotension. He did very well, and I was able to remove the tumour. But that information…you may have operated on 3,000 spinal or brain tumours, it doesn’t make a difference. Because this is functional information, on the tolerance and the subcortical ischemia threshold for that patient, that only monitoring can provide you.”

“Fred Epstein, they started to use monitoring when they were at the top of their career. So they didn’t need monitoring to perform better or to be more famous worldwide. They were already recognised as outstanding surgeon, spinal cord/brain tumour surgeon, but they’ve picked up the importance of that, they were very open when they were 65 year old to adapt their surgery to neural monitoring. On one side if you are very skilful the cases where you will have troubles are less, so monitoring can make a difference to a lesser extent, but consider with the cases where you cannot have certain information without monitoring. I think that we have improve the evidence for the value of neural monitoring; there is a lot of debate on the evidence based medicine of neural monitoring, although I have to say that the evidence we have for neural monitoring is no less than the evidence we have for neurosurgery, but that one is not questioned.”

“I think that we have to be very cautious in defining something as a standard of care when there is not enough evidence. But at the same time, this cannot be an excuse to justify surgeons who operate on a spinal cord tumour without neural monitoring to say there is no evidence so you can do it without it. In general, in spine surgery the vast majority of spinal surgeries you don’t strictly need neural monitoring for all cases. It’s much worse to have it and not use it than not to have it and do the surgery. Then it’s up to the surgeon to say ‘okay, I will refer my patient to someone who has the support to do this with monitoring’ rather than ‘I will do it by myself’. Here you clash with the very strong neurosurgical ego! (laughs)”

Prof Sala continues to investigate novel applications of neural monitoring, more recently involving the possibility of permitting asleep brain tumour surgery for awake brain tumour patients via mapping of cortico-cortical evoked potentials (CCEPs) involving the arcuate fasciculus. When asked about his philosophy towards mapping of the human brain, Sala is quick to reference the progress of neural monitoring in general. “I think there has been a big jump in the late 1990’s early 2000’s in terms of techniques, new techniques…but then really, the last twenty years, there has been not much new stuff coming out. A few papers here and there, but especially we are not doing much different now than we were doing twenty years ago… The more we look carefully at motor tasks the more we realise that the MEP monitoring of the corticospinal tract and the other systems are essential to predict and prevent an injury, but they don’t cover everything. That’s because motor control is much more complex than just the M1 corticospinal tract. For example Prof Hugues Duffau claims that you should perform all surgeries awake also for those strictly related to motor areas, because you can assess not just moving/not moving corticospinal strength MRC scale, but you can look into the more complex scenario of apraxia, of motor control, or supplementary motor area (SMA)…the problem is that not every neurosurgical centre is possible to do all the patients awake. So you have to find a way also to keep surgery safe under general anaesthesia.”

“We’ve started to investigate, at least the possibility, to look at other ways to map and monitor the motor system. For example we have seen that you can modulate the M1 output by stimulating the parietal lobe cortex. This is well-shown in monkeys but never shown in the operating room. We did this study last year, and you can stimulate the parietal cortex and modulate the output of M1 (which) either decreases or increases the MEPs. We have recently did something to start investigating the cerebellar mutism in children. Patient operating in the posterior fossa, unable to move and speak after surgery, and here there is this dentato-thalamo-cortical pathway which is involved. Interestingly on the cerebellum there is nothing in terms of neural monitoring. So we have completely ignored the cerebellum, (and) putting all the attention on the brainstem.”

“Talking about CCEP and language, the assumption is that we would try to find a way – taking for granted that awake surgery is the gold standard when you are dealing with cognitive problems, you cannot do awake surgery in all patients. We’re trying to see if it’s possible to replicate in the OR, and under general anaesthesia, what Matsumoto published ten years ago in awake patients where he was able to stimulate from Wernicke and record from Broca, and vise versa, through the arcuate fasciculus in awake patients. We published this very preliminary pilot study which of course needs validation by other centers and a larger number of patients but at the beginning looks still in the clinical correlation. But at least we were able to reproduce basically the same data from Matsumoto meaning that you can stimulate the arcuate fasciculus and if you can monitor that, that might eventually be one way to keep under control at least….which is not everything you need to speak, but is one important pathway”

“We should to some extent see if we can find from a neural monitoring perspective what we have found from tractography and DTI in terms of imaging of the subcortical white matter tracts in the brain. That has been a revolution for us in terms of neurosurgery, but that’s anatomic information not functional information. Also has some limitations but is very important. If you can combine tractography and I think the navigated TMS is a very useful tool to validate tractography, it can also have and we are using that in stimulating the arcuate fasciculus to try to find the hotspot in the Wernicke’s area and the Broca’s area for where to start stimulating and recording. This is very, very preliminary, but there are small groups internationally and I think it’s a worthwhile pathway to investigate. Whether or not it would make a difference clinically, only time will tell us.”

“The principle of brain function as switched from the concept of eloquent areas to the concept of the connectome. I think neural monitoring should also probably follow this to some extent, and besides mapping, try to see if we can now also investigate the brain. With the over-principle of neuromodulation… you may induce neuroplasticity to some extent, so it’s opened up a completely new field. I think neural monitoring provides an opportunity to increase our knowledge on brain function.”

Medical technology continually alters treatment opportunities in all aspects of medicine, including surgery. Recently, and on the global stage, there has been a radical increase in robotic-assisted technologies and high resolution imaging that focuses on structural information rather than functional information. “I think the philosophy is that neurosurgery in the third millennium should be functional. I’ve recently been invited to give a talk at the Italian Neurosurgical Congress during the plenary session on functional neurosurgery. I’m not a functional neurosurgeon at all, I don’t have experience in deep brain stimulation (DBS), I did very few rhizotomy…but I think there is nothing more functional than neurosurgery with monitoring. Neurosurgery should be all-functional to me nowadays, and monitoring is one way to approach that. When you do that you do that for the purpose of making the surgery safer for your patient, and at the same time you can learn more about that specific patient and how the brain works, and the more you know about how the brain works, the more you can improve the safety of your procedure. I think the two work in parallel, as much as you do it properly and if you don’t have complication, and the patient is aware of that.”

Amidst the day to day management of a neurosurgical unit, academic appointments and lecture circuits, Prof Sala finds calm in tennis and mountaineering, which is of no surprise given his proximity to the Vicentine Alps. “Though I’m not a climber, (I enjoy) trekking and mountaineering, skiing and hiking in the dolomites. I like going to the mountains, I play tennis, I do some sports, stay with my family. But certainly mountains are a place where I go when I need to find myself and to recharge the batteries. I’m lucky because I love what I do, I love my job, and this is important because when you spend twelve hours in the hospital either you like it or it’s a nightmare. I like it from that point of view. What inspires me? I try to do my work at my best, I have a wonderful family supporting me, and I think that gives you balance in your life, because I love neurosurgery and I love neural monitoring but I didn’t marry them. I married my wife (laughs). That’s what counts in life. Balance is important. And then, it’s rewarding to see your patients doing well, and people being happy.”

“As a neurosurgeon of course you face your failure, and your bad cases, and those are the cases you remember much better than those who went well. That’s part of the game. I think that neurosurgery is still a fantastic branch of medicine. I don’t think it’s the best one – it’s the best one for me…but I think it’s fascinating because there’s still the opportunity to do your clinical work, and you’re dealing with an organ – the brain – which is still being investigated. I like it because it’s challenging, because it’s fascinating. For those that are young neurosurgeons, and wonder whether or not neural monitoring could be a good (career) investment, I think it could. They should just be ready and available to invest time. I don’t think neurosurgeons should become neural monitoring experts, but it would help them especially the young generation because they will have the neural monitoring every single day to know a little bit of that. They should not just pass this to the neurophysiologist or technologist and say you do whatever you have to do and tell me what I want to know.”

When asked to consider advice to those interested in a career in neurosurgery or clinical neurophysiology, “…do what you like to do. For a career you have to consider many things…for example, my oldest son is willing to become a movie director. When he told me he would like to do film making I said ‘look, okay. I don’t know anything about it so I don’t know how to help you. To me it sounds like…” He pauses. “…I want to become a tennis champion. Those who start with the idea of becoming a tennis champion will end up teaching tennis. There is a lot of selection in that. But I told him, if this is what you love to do, then go for it. I will support you as much as I can. Because I think that’s important: if you don’t like what you do, what’s the point of going to work every day, and that will frustrate you as a human being, as a professional.”

Throughout our conversation, it’s clear that Prof Sala feels a sense of duty to the wider neurosurgical community as much as he does for the scientific community. He speaks with balance and consideration, and is quick to acknowledge the imperfection of neural monitoring as a clinical investigational tool rather than an obligatory medicolegal requirement. There is an impression that the attitudes surrounding the controversial aspects relating to monitoring are thanks in part to ambiguous accreditation processes in addition to imbalanced assessments described amongst peer reviewed literature. Of course, this might also be attributed to the commoditization or industrialisation of clinical neuroscience, which has a tendency to bastardise clinical education and training programs in lieu of financial opportunities.

“Going back to the very beginning, I thought several times over the past few years, when I came back from new York, for a few years I was the neural monitoring kid. I was the one who came back from the States, the great stuff. But practically, I was spending my days putting in electrodes, monitoring patients, for my boss and for my colleagues doing the surgery. From a neurosurgical perspective they were having the good stuff, and I was doing the monitoring for them. There had been a few years where I thought maybe I was just stupid, that I’d done the wrong thing, because…when I came back from New York, I was almost offered a position in Boston at Harvard to lead the neural monitoring team. And I said, ‘no, that’s a great opportunity but I would never become a neurosurgeon’, and that’s what I wanted to be. I came back here and for a few years I struggled with this. At that time I didn’t have much of a chance to do surgery, so it took me longer compared to my colleagues to do complex cases myself. Interestingly, the expertise and the reputation I built up in the neural monitoring field turned out to be the key for me to be acknowledged within the neurosurgical community. First I started to attend and be invited to the neural monitoring congresses and courses, and then we started to publish the papers, and I started to be more involved in research by the neurosurgical societies and I started to give lectures more and more in the neurosurgical communities, and ultimately of course I started to do surgery and now I’m enjoying doing surgery with expertise in neural monitoring, which is very nice because you can use this technique for your own surgery now.”

In context of the extensive practical training suggested by Prof Sala, it is of no surprise that he promptly acknowledges the risks associated with surgeon-driven monitoring systems as they foster the idea that no clinical expertise is required for the correct interpretation of electrophysiologic data. However it is evident that his philosophy regarding clinical practice has not strayed far from what he reported in publications over twenty years ago, “… we would certainly require somatosensory evoked potentials and motor evoked potentials to be monitored much as we would require a parachute jumping out of a plane at 3500m”. Nevertheless, as Sala points out, neither neural monitoring nor the use of a parachute has been validated by level one evidence-based medicine.

As our conversation comes to an end, I can’t help but reflect upon the so-called synchronicity of Sala’s career, and the opportunities it has afforded him; his interest in the circulatory system of small fish. His first introduction to the operating room at the end of high school to help his Uncle. His travel to Austria where he first observed the human brain. And of course, his multiple tenancies in New York, with great risk of derailing his neurosurgical aspirations. When I ask Sala whether he considers a moment in his career to be the highlight, he pauses at length, then laughs.


He digresses.

“Probably the highlight was giving credit to Professor Bricolo and Professor Deletis twenty years ago, “don’t worry about surgery, you will do the surgery you will learn surgery one day. This is a unique opportunity for you to learn something with may affect your entire career”…and they were right. They were right. But…I was a bit worried at the beginning for a few years.”

“Now? Things just took their own way, the right way.”



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