Of scalpels and bone cutters: Studying at the Neuroanatomy Lab

One Friday morning in July, about a hundred students of medicine filled the rows of the main auditorium at LMU’s Institute of Anatomy, peering down at four senior physicians decked out in operating gear and standing around a body donor. The doctors had been given a special leave of absence to give the students a detailed demonstration of how to operate on the spinal column. The object of today’s lesson – “Neuroanatomy Lab Part II: Spine” – was to let the budding medics an peek into the world of neurosurgery and give them an idea of whether this discipline might be something for them. It should prepare them for hospital life and show them what the reality feels like, not just in theory.

A live operation and subsequent work on the body donor are regular and important features of the Neuroanatomy Lab, as the students had already found out in “Part I: Cranium”, where the skull was the center of attention. Slipped disks, tumors, broken bones: Practice, rather than theory, is the focus of this module. And the best way to simulate surgical practice is to use body donors, says Robert Klövekorn, who founded the Neuroanatomy Lab. “As well-designed and well-built as any model may be, it will never look exactly like a real human being on the table in the operating theater,” Klövekorn states. Haptic feedback – a feel for how far you can and should go – plays a vital role in live operations. How far do I have to drive a screw into the bone so that it is nice and tight? When should I stop to avoid doing any damage? Body donors are tremendously valuable to help answer these questions. Why? Because later on, when training as a junior doctor, “Your responsibility for live patients is completely different,” as Klövekorn puts it.

There is so much that you can damage

The senior physicians from the neurosurgical wards at Munich University Hospital and the Rechts der Isar Hospital were busily palpating the body donor’s spinous processes, cutting open the skin down the center line, pulling the muscles away from the spinal column, cutting deep into the bone (albeit very carefully, to avoid damaging the dura mater, the mantle of the spinal marrow), making deeper and deeper incisions until they reached the intervertebral disks. A camera hovered over them, hooked up to a beamer to project every detail onto a huge canvas in the auditorium. “It’s crazy when you think of everything you could damage,” said Dennis, an 8th semester student. “A millimeter too far and the patient could be paralyzed for life.”

This was the first time that Dennis and his fellow students Franz and Eloy had been to the Neuroanatomy Lab. They are in the seventh and eighth semesters respectively, so they have already long since completed the dissection course. Sometimes, however, they feel that their course contains too little surgery – which is why they were attending the event in question. Which is right where they should be, in the view of Klövekorn, the sole organizer of this series of events. He himself was studying medicine in the 11th semester at LMU Munich, and he wanted the Neuroanatomy Lab to plug a gap in the system. The medical degree curriculum is full to bursting and gets fuller with every passing year. The course content grows as medicine progresses. And it is rare for subjects to be dropped.

Time for the brain, spinal column and neurosurgery

There is no getting away from the fact that all the students need a general medical education. “So, you are left with only a limited number of hours for neurosurgery,” Klövekorn explains. “The course then has to move on to other subjects: heart surgery, ear, nose and throat conditions, dermatology, they all need attention, too.” He therefore wants the Neuroanatomy Lab to devote time to the brain, spinal column and neurosurgery as well. Moreover, it should be just as useful for enthusiasts as for doubters: “For me personally, I very quickly discovered my passion for neurosurgery,” he says. “I was fortunate. But not everyone finds it so easy to decide.”

The students in the auditorium were beginning to get restless: They knew that the operating lesson was drawing to a close, and that it would soon be their turn. The first white coats were appearing on desks: The students still had five more stops to cover along the way.

Practice makes perfect

The anatomical dissection room has a large glass dome and is flooded with light. The hum of the air-conditioning is constantly audible. Here, medical students in the first two semesters get to know human bodies from the inside for the first time. On this particular day, private lecturer Dr. Nicole Lange, senior neurosurgeon at the Rechts der Isar Hospital, was standing in front of them – with another body donor ready and waiting behind her. The body had already been “carefully prepared”, as she noted, which means that the bone marrow and its nerve ends were exposed and waiting. The students touch the bone marrow, test the stability of the nerve cords and familiarize themselves with what might one day be part and parcel of their daily routine. Dr. Lange was at pains to allay their fears: “It’s all a question of practice. Everyone can learn it,” she asserted, showing them the various operating instruments: the punch, which is good for getting under the bones, the dura mater forceps with an extra-fine point, the periosteal elevator to scrape muscles off the bone, and the bone punch – an instrument with which to expose the bone structure of the spinal column. Dr. Lange patiently answered questions, explained who is allowed to operate at the hospital, talked about how to know whether you are damaging the dura mater – and how she ended up in neurosurgery. “Great!” said one elated student, “I’ll come to you for my practical year.”

Neurological status and imaging are important

Meanwhile, ten or so students in the room next door were straining their necks and standing on tiptoe, trying to catch a glance of Dr. Raimund Trabold’s hands. Dr. Trabold is a senior physician at Munich University Hospital and had just finished using two models to explain how to insert cages, pins and plates – implants and pedicle screws, in other words – into the cervical vertebrae and the lumbar spine. In front of the body donor that had just been dissected in the auditorium, he stood waiting for his instruments – a job for which Sven Frenzel from medical technology company Signus was responsible on this day.

While Trabold was still finishing his explanation, Frenzel made a beeline for one student, told her “You are perfect for this job” and placed two tools in her hand. “You need that one first,” he added, pointing to the thread cutter. The students would now use this to drill a whole in the bone. “Press, press, press,” Trabold urged until the hole was ready to take the screw. The stability of the screw was then tested: “The head wobbles, the rest is stable,” another student commented. Fine: The head is supposed to wobble so that it can be adjusted later on, Trabold explained. Those who could not gather round the body donor practiced driving screws into models. It squeaked and scraped a bit but seemed to work.

In the meantime, Klövekorn moved around to the various stops in the lab, checking whether everything was alright. “You don’t just go ahead and operate because someone has a pain in their back, of course,” he said. “You first examine them, which is why the neurological status and the imaging are so important.” Dr. Kaywan Aftahy from the Rechts der Isar Hospital was in charge of imaging today. Using case studies, he explained to the students how to interpret the images and talked about the benefits and drawbacks of different spinal imaging methods: CT, MRI, ultrasound, CT myelography and conventional x-rays: “You can do them anywhere, but you don’t really see anything,” he grinned.

Practising on models

A yard or two away, one student was just taking his shoes off. He had volunteered for a neurological examination with Christopher Hemingway, junior doctor at Munich University Hospital’s Department of Clinical Neuroimmunology. Hemingway pulled a toothpick out of his notebook, broke it and demonstrated how to examine the patient with sharp and blunt objects. He then tapped the “patient” with the reflex hammer and explained how the MRC tests levels of strength. Inspired by the demonstration, one student tried using her mobile phone to trigger a reflex in a fellow student. “I can’t bear to look,” Hemingway smiled, handing her the reflex hammer and adding: “It’s more of a pendular movement you have to do when tapping the patient.”

Half an hour before the end, one student was waiting for her last activity with Dr. Tobias Greve from Munich University Hospital. “Senior physicians so rarely have time for you,” she said, “and here we have four of them all at once.” The doctors answered questions about the practical year, about their career to date, offered help with clinical traineeships and generally tried to have a calming influence: “Ultimately, it’s just a skilled trade. And if you like it, you like it. If not, you can switch to another discipline,” Greve shrugged. “There’s no harm in that.”

The senior physician took the students over to the RealSpine models where they could try doing an operation for themselves – including artificial skin, artificial blood, artificial bones, the works. “It’s a real battlefield,” Greve said. The work of the other groups had left its mark, but there was still plenty to do. Greven handed out operating instruments and gave instructions: “Here you have to scrape the muscle off the backbone”; “No, that is not yet the spinal disk”; “The bone needs to be cut away there”; “Here you can chisel away the joints, too.” One student bravely grabbed the hammer. “But be careful with the dura mater,” Greve called as she hammered away. “This kind of event is important,” he said. “How else can you get young people excited about the subject?”

Robert Klövekorn had just said goodbye to the last lecturer and said his thanks to people in the auditorium: to his friend Clara Clemens, who had helped him sort things out on site; to Professor Jens Waschke and Professor Anja Horn-Bochtler from the Institute of Anatomy, who funded the lab. A seven-and-a-half-hour excursion into the depths of neurosurgery was now at an end, and Klövekorn was sitting in one of the anatomical classrooms. He still wanted to tidy up, but nevertheless took the time to sum up the day.

“One of the most time-consuming things I’ve ever done”

This was essentially his show. He had been organizing it since the previous October. He alone had fleshed out the concept, talked to the institute about the possibilities and what body donors would be available. He had thought about which lecturers and hospitals he would approach, written dozens of mails and even produced a short trailer. He had no idea how many hours he had spent on the project: He just did it, during his state examinations, during his practical year at the University Hospital of Zurich. After ten or twelve hours at work, his “evening off” was then often enough spent writing mails, clarifying details and making further plans. A day before the event, he was still working at the hospital. So, he took a day’s vacation, drove from Switzerland to Munich and stayed up late into the night assembling the various presentation pieces. A lot of work, it seems…

“Apart from my doctoral thesis, this is one of the most time-consuming things I’ve ever done,” Klövekorn admitted. Just before the end, however, a student who had to rush to get her train came and told him that she was just doing her second clinical traineeship. She thanked him for the event and said: “I’ve learned more today than I did in eight weeks’ traineeship.” That is exactly why Klövekorn does it, that is why it is worth the effort. “To give students this experience on which to base later decisions, and to do it at such an early stage, that is really fantastic,” he says. That is also why he wants to carry on.

But first he will finish his practical year. Then comes his third state examination, and soon there will be another edition of his Neuroanatomy Lab – by which time he might already be a freshly licensed doctor. “I’m certainly not going to give this up,” he says. Teaching is his thing, and so is neurosurgery. Later, he would like to work at a university hospital. And he wants the Neuroanatomy Lab to keep going – either with a repeat of part I (Cranium) or with something completely different. There is plenty to choose from in neurosurgery, he comments. That said, he doesn’t want to give all his ideas away just yet. He thinks for a moment and grins: “The ideas first have to simmer a bit in the dark recesses of my brain.”