Dr. Joaquim Enseñat: “Neurosurgery is starting to treat severe depression and, in the future, patients with some types of pain”

Neurosurgery is a complex and varied specialty, which is constantly changing.  It requires dedication and continuous study.  We do not reach our highest level of technical perfection until we have acquired many years of experience.  Each surgery you perform is a challenge. The anatomy of the brain is very complex because it is not always the same. In other words, the head is never in the same position.

Neurosurgery is a way of life. We are people, we are parents, we are husbands, but we are also neurosurgeons, in other words I am, and I think that all neurosurgeons are very dedicated people, our whole life revolves around this.  For me, it's not even a job, it’s a passion.  I don’t know any of my assistants—and I include myself here too—who don’t go to work happy, because we love what we do. Apart from being a job, it’s a hobby, it's fun, and it’s a way of life.

I wanted to be a basketball player, but I was also passionate about the idea of being a neurosurgeon. When I started studying, I saw how the brain worked and at the same time realized that I liked surgery. I suppose the combination of these two things led me to bring this idea I found so exciting when I was young to fruition.  In fact, I studied in Reus and there is no neurosurgery there. So, during the six years of my degree course, I was not able to study this subject. I began when I finished my course and had to choose my specialty. At that time, I tried to find a place where I could learn it.

It is so complex because we can do a lot of damage.  Bad surgery can have permanent consequences for the patient and can change their life completely. We can create serious problems and, because we are very aware of this, our surgery is designed to avoid this happening.  Sometimes, the tumours themselves complicate the situation a great deal.  Sometimes, these deficits are insurmountable, or occasionally require very refined surgical techniques in order to remove the tumour without causing these deficits.  This puts a lot of pressure on us. This is why it is so complicated, because we are very afraid of hurting people, and we can do so very easily. Is it a specialty that is complicated both surgically and psychologically.

The technical preparation is a process.  When you are a young surgeon, you cannot perform certain surgeries.  There is a learning curve; first of all you perform easy operations and then more difficult ones. Moreover, you are accompanied by more experienced people, which allows you to improve without hurting anyone.   One exercise I suggest to my assistants is that they reproduce the whole surgery the night before the operation.  It helps us a lot to have neuroanatomy laboratories, in order to learn approaches that have already been described and new ones too. They are useful for research.   In these laboratories there are brains of people who decided to donate them to science, and there are microscopes and navigation systems that allow us to operate.  The idea is to reproduce what an operating theatre would be like.

The technical preparation evolves in parallel with the psychological preparation, but not everyone can become a neurosurgeon. I think it is a process in which you learn as you go along.  The first time you have a problem and the patient suffers is a terrible blow.  I think it is essential to maintain a certain emotional distance from the patient. If you don’t, you can’t operate. But we must not forget the human side.

The main difference from when I arrived is that nowadays we have very good preoperative planning with 3D systems that allow us to see where the tumour is and what type of approach to use. We have a very important intraoperative imaging, very good microscopes and navigation systems, and very good intraoperative magnetic resonance imaging, which allows us to know where we are at all times.  There is also a neurophysiological part, which allows us to see the neurological function.  Sometimes we operate while the patient is awake and if, for example, we affect the language area, we can see this.  If we have to operate on a tumour in the language area, the only way we have of knowing if we will leave the patient speechless during the operation is if the patient can speak, so we allow them to be awake during the operation, with the appropriate medication so that they do not feel any pain.

On the other hand, minimally invasive surgery such as transorbital surgery, an important branch of my specialty, has resulted in a remarkable improvement in neurosurgery.  There are fewer aesthetic defects and the patient can go home within 24 hours. The idea is that they go home without anyone asking them whether they have had an operation.  We don’t cut their hair, we make no visible incisions…  In the past, we had to make a large opening and the recovery involved hospitalization for 10 days to 3 weeks.

We also perform functional surgery in which we use brain stimulators to improve the symptoms of patients with Parkinson's disease or severe epilepsy.  In the latter case, we are talking about patients who may have 20 seizures a day. The idea is to locate the part of the brain that produces this epilepsy and, if it can be removed, this is carried out, as long as the sequelae are manageable.

We are starting to treat psychiatric patients, for example cases of very severe depression that can be treated with neurosurgery.  And, in the future, we would like to perform pain surgery. It has been seen that certain deep brain stimulations can alleviate some types of pain in patients.  There are areas of the brain that are involved in pain processes. Putting an electrode in these areas may stop these patients having these episodes, but research is still ongoing on this subject.

Before COVID, we went to Africa to perform surgery, more specifically on young people, on children.  We were in Tanzania (Zanzibar), and then in Kenya, (Mombasa), sponsored by FAHiD (the Hospital Clínic Humanitarian Aid and Development Fund). It is worthwhile experiencing life in these countries, because it reminds you why you became a doctor. It is something we should all do.  Here we complain we don’t have enough resources, but there you become aware of the real situation. Without resources everything is more complicated.  For example, in the operating theatre there was no light and we could only operate when we had natural light.  Despite that, I never saw any family abandoning a patient there, even if there were children who did not have a family, there were people there who adopted them, and that does not happen here.  Whenever you saw a patient, there were 4 or 5 people around them.  They do not have resources, but they have a sense of humanity that is often lacking here.

The greatest success is all the patients who have done well.  Or if they haven’t, when the family thanks you it is very gratifying, because sometimes medicine is not about saving lives, it is about helping people to die, improving the patient’s quality of life…

And I think one of the greatest challenges is being head of service.   I like to call it "emotions manager”. Leading and making the team better every day. It is a challenge to make everyone understand your way of seeing things, to ensure you are able to be flexible…  You need people to come together as a group. We all need to help one another to ensure the patient does well. And when this happens, it is a success for everyone.