For this operation, the surgical instruments include a guitar

As the first few notes of Radiohead’s "Creep," strummed to life inside MD Anderson’s BrainSuite® operating room, a tear welled up in neurosurgeon Sujit Prabhu’s eye.

"I thought, 'Oh my god — we pulled it off!'" recalls Prabhu, a professor of Neurosurgery.

The music wasn’t coming from a speaker. It was coming from the other side of the sterile surgical drape, where 24-year-old musician Robert Alvarez lay on the operating table, playing guitar during his brain tumor surgery.

While playing music during minimally invasive deep brain stimulations is relatively common, bringing a large instrument into an intraoperative MRI suite during open, awake brain tumor surgery is not — and the potential complications are much higher. But Prabhu and Alvarez agreed the challenge was worth it to protect what was most important to Alvarez: his ability to create music.  

A patient-centric approach

Alvarez was diagnosed with a low-grade brain tumor in 2013, when he was age 19. Although the tumor crossed the insular, frontal and temporal lobes of his brain, he didn’t have many symptoms then. He was worried about the risks of surgery and decided to postpone treatment to focus on his music career. The choice made a distinct impression on Prabhu when they met in January 2018, after Alvarez began having seizures.  

"How many people will sit with a brain tumor for years and be creative, knowing you have a ticking time bomb?" Prabhu asks. "At any cost, he wanted to play music."    

To take out the tumor, Prabhu would have to navigate through areas of the brain connected to speech, motor function, emotions, memory and mood.

"A complication in these areas as a result of surgery would take away his ability to play," Prabhu says. "We’re still at a crossroads trying to understand brain connectivity as it relates to individual patients. We know certain areas of the brain control certain functions, but the connections are much more complex than we ever thought."

An awake craniotomy

Neurosurgeons use sophisticated tools before and during surgery to map these connections, with the goal of protecting critical brain functions. When the tumor is in an area of the brain that controls speech, motor or sensory function, the best approach is a surgical procedure called an awake craniotomy.

During the surgery, the patient is awakened mid-surgery for a series of simple neurological tests. This gives the neurosurgeon valuable, immediate feedback about how much tumor can be safely removed.

"We have to be very precise," Prabhu says. "Even a few millimeters can make a difference."  

The brain has no pain fibers, so applying local anesthetic to the surrounding skin, muscle and dura mater allows the patient to remain comfortably awake for the critical part of the surgery. Doctors at MD Anderson perform nearly 100 awake craniotomies every year. Prabhu recognized that the ability to create music, however, is far more complex than the standard neurological tests could convey.

"Music comes from the heart," Prabhu says.

Maintaining patient safety

To protect the young musician’s livelihood, Prabhu asked Alvarez to play the guitar during surgery. That presented several challenges:

• The surgery took place in the BrainSuite, a specialized neurological operating room with an MRI magnet weighing 7.5 tons. The magnet would easily pull in Alvarez’s electric guitar, so he bought and practiced with an acoustic guitar for the surgery.
• Usually, patients lay on their side for an awake craniotomy. Most musicians play the guitar sitting or standing. The team had to find a compromise that would allow Alvarez to play comfortably with his head fixed in place while Prabhu operated.
• A sterile surgical field is necessary to prevent infection, but Alvarez couldn’t play the guitar if he was literally draped in surgical drapes. The OR nursing team suggested using MRI-safe poles to hang the surgical drapes like curtains instead.

"Our primary focus is making sure the patient is safe," clinical OR nurse Michelle Brents says. "We keep the same, safe standards because when you change things, you can end up with problems."

To avoid problems, the entire team planned extensively. Brents joined Alvarez, Prabhu, neuroanesthesiologist Shreyas Bhavsar, D.O., two MRI technologists and a surgical technician in the BrainSuite for a dry run the day before surgery.

"We brought him in a day early to get him familiar with the environment and to make sure the draping and positioning we planned would be feasible," Bhavsar explains.

The next day, "everything just worked like a symphony," Prabhu says.

Alvarez sang the same tune and played the same rhythm he had the day before. At times, when his playing faltered, Prabhu backed off and operated in a different part of the tumor.

"I removed more of the tumor than I expected," Prabhu says. "I wouldn’t have pushed it as much if he wasn’t playing the guitar." Prabhu safely removed 90% of the grade II astrocytoma brain tumor. After healing from surgery, Alvarez completed proton therapy and began chemotherapy this past summer.

"I’m looking forward to chemo being finished, but I’m still playing my guitars and writing lyrics," Alvarez says. "I’m just really grateful."