My name is Andrew Jack, and I am a peripheral nerve (PN) surgery fellow at the University of California San Francisco (UCSF) with Dr. Line Jacques. As a medical student, my interest in PN surgery was cultivated early after having spent some of my elective time with Dr. Raj Midha at the University of Calgary. I found the diversity of the anatomy and its ability to localize patient complaints captivating. However, throughout my neurosurgical residency at the University of Alberta (and likely in-keeping with most other neurosurgical residencies) I had very little exposure to PN surgery. As a result, I gravitated toward spine surgery. While at a review course as a senior resident, I heard Dr. Jacques give a presentation on PN trauma and tumor management. Listening to her present, I was immediately reminded of what had interested me about PN initially. I spoke to her after her presentation about my interest in it, and she mentioned that she had recently moved from the Montreal Neurological Institute to UCSF. Over the next six months, we spoke several more times, and she created a PN fellowship for me at UCSF to start after my spine surgery fellowship in Seattle.
More recently, at the Kline Legacy Peripheral Nerve Dissection Course in New Orleans I had the opportunity to meet and dissect with Dr. David Kline (whom I’m sure needs no introduction). He talked to me about the importance of mentorship and how lucky I am to be working with Dr. Jacques, comparing the PN community to a family (which I then liken him to being the grandfather passing on his wisdom down to me through his mentee and my mentor, Dr. Jacques). It was that comment that inspired this article and allotted me the opportunity to interview one of the giants and pioneers of PN surgery, Dr. David Kline.
Dr. Kline:I’ve had so many mentors that I’ve been privileged to work with during my career. Dr. Richard Davis was one of my first mentors at Penn [University of Pennsylvania] as a medical student. He was such a patient, humble man, whom I admired greatly. He gave me advice about the field of neurosurgery (NS) and possible training sites. My first real experience doing PN research came at Walter Reed with Dr. George Hayes and his residents at that time such as Ludwig Kempe, as well as the faculty at the Army Institute of Research.
I met Hayes at his office after receiving a draft notice and finding that I was to be replacing a dentist at Ft. Riley, Kansas. At the time, I was a general surgery resident at Michigan [University of Michigan], and I had been due to start a NS residency in July. A friend from high school was training in Orthodonics at Walter Reed, and suggested I travel to DC and visit the Surgeon General’s office to see if I could add some hospital experience in Kansas to my soon-to-be field duties at Ft. Riley. After an abortive visit there, I hunted up the head of NS who was Col. George Hayes at Walter Reed. After a long wait outside his office, I was taken in and on his examining table was a Dachshund Dog. It was obvious that the dog was having trouble moving his rear legs. Standing next to the table was an Army General. Hayes asked me not why I was there, but what I knew about dogs and how he might get a myelogram done without drilling a hole in the dog’s head which the General did not want done. After some discussion, Hayes asked me if I wasbusy, and I said “No.” So, he said “Pick up the dog and follow me.” We went to the 2nd floor of Walter Reed Hospital where there was a diagnostic radiology room, as well as ORs [operating rooms]. After anesthesia [induction], Hayes walked a spinal needle down the occiput, tapped the cisterna magna, and injected several ccs [cubic centimeters] of dye. The dog had a total block at T7-8. Hayes said he needed a cup of coffee and a smoke so he told me to follow Sgt. Cann to the OR and to shave, prep, and drape the animal’s back. As I did this, I noted a brass plaque on the OR table stating that former President Dwight D Eisenhower had had a partial colectomy there. Hayes was a quick and clever surgeon—he gently displaced the cord after sectioning some of the dentates [dentate ligaments], and did an anterior durotomy to extract the offending disc. He asked me to close even though I told him I had no NS experience. Later in the changing room, he asked whether I felt the General owed me a favor for helping. I, of course, said “No” and felt the General, who turned out to be head of the Walter Reed Army Institute of Research, owed Hayes a large favor because his dog might recover a good deal of function. Hayes asked whether I had had any research experience, and I again said “No” which he said was good since he did not want someone with preconceived notions! He explained that he had been involved with many nerve injuries in wartime, and much of the work had been based on experimental papers using rats, hamsters, rabbits, and dogs, and that he had always wanted to do a study involving primates—especially higher primates. He asked if I would be interested after basic training at Ft. Sam Houston in coming to Walter Reed? And, of course, I said “Yes!!!” The Lieutenant in charge of us at Camp Bullis in the desert outside of San Antonio had started as a private, and it had taken 12 years to reach his rank. During that time, he had repeatedly tried to get assigned to Walter Reed and failed. As a result, he was most unhappy with me when at the end of training he had to transmit a change of orders for me to go from Ft. Riley to Walter Reed, but that is how I became involved in matters involving nerves.
Dr. Hayes first charge to me [at Walter Reed] was to find out what a plastic adhesive (Ethicon Inc.) did to nerves that a California neurosurgeon had come up with to use for aneurysmal repair. That upset Hayes because he and Dr. Dutton had developed an aneurysmoplastic technique using methylmethacrylate to coat aneurysms, which he hoped to publish. The California neurosurgeon though had all of a sudden gained fame by using this new adhesive to encase and treat an aneurysm in a famous Hollywood movie star. So anyway, I painted some of it on surgically exposed research animal nerves and then removed it at a later time to study them [the nerves] histologically. The adhesive seemed to be quite damaging! I was worried that Hayes would think that I had been clumsy or rough with the nerves so I did a craniotomy on several Rhesus monkeys and retracted the frontal lobe to expose the optic chiasm as I had seen Hayes and others at Walter Reed do. I’d then put a drop or two of the adhesive on the chiasm and then reoperate a few months later to find a damaged optic chiasm. Hayes was very pleased with that, and he invited me to go to my first AANS meeting to present our findings. He made sure to invite the Hollywood neurosurgeon and the manufacturer to hear our observations. And I remember it was pretty uncomfortable and telling Hayes that this man will probably never forget me, and he said “Well he shouldn’t! He needs to know!”
At the University of Michigan, which is where I had returned to complete my training after Walter Reed, I learned a great deal from Drs. Edgar Kahn, Richard Schneider, and Elizabeth Crosby (a neuroanatomist). Each were experts in their field, and I’m immensely grateful for the time they, as well as that that their younger trainees such as Jim Taren, Sid Farhat, and Bud DeJonge spent with me. When I had returned, they asked me where I wanted to rotate, and what I wanted to do. I said that I’d appreciate being at a hospital where I could not only teach, but also learn from faculty how to run a service. Now I know you may not believe this, but many of the nerve cases that came in (except carpal tunnels which Eddie [Dr. Kahn] loved and could do so fast) that Drs. Schneider or Kahn (and sometimes Dr. DeJonge) received, I was asked to do. And that’s the way it had been at Walter Reed too. A number of times, the resident was so busy with head and spine [cases] that I was asked to help out or even do the case. Dr. Schneider of course had been in Italy during WWII, and said to me once “Dr. Kline, if I never have to do another nerve case in my lifetime, I will be a happy man. It is very difficult work; it requires a lot of perseverance and patience, as well as hard work and knowledge because nerves can get injured all over the body. You need to know the anatomy, physiology, biochemistry.” True to his word (as well as Dr. Kahn’s), I did many of the nerve cases while I was there.
Of course, after Michigan I went to Louisiana right after Dr. Peter Jannetta started in 1967. I had a lot of mentors and colleagues there too. It had been Jannetta, in addition to Drs. Isadore Cohn (Chair of Surgery), Dr. Paddison (Head of Neurology), and Dr. Dean Echols who convinced me to come to New Orleans. Echols had told me that once I had arrived, to be well prepared and willing to take on anything and everything because of how crazy the cases, the competition, and medicine in general was there. “But it’ll be worth it,” he said, “it’ll be worth it.” Dr. Cohn had been anxious for Peter and I to become staff members at Touro, a very old private hospital in N.O. [New Orleans]. Many in the hospital felt no more neurosurgeons were needed, but the chair of the committee charged with keeping us out (and whom tried his best at doing so) then admitted that their by-laws would not tolerate that [excluding us] if we met the hospitals’ staff requirements. He then told me that he and his partner in private practice there would stand ready to help us if we ever needed help at Touro. Turns out that both had been in charge, although having full private practices, of the LSU NS service at Charity [Hospital] for many years.
Dr. Kline:At Charity, we used to have general surgery residents perform lumbar punctures, myelograms, pneumocephalograms with the radiology technician’s help. I came there one time to find the resident having fallen asleep draped over the patient. You see, pneumos [pneumocephalograms] used to be done with the patient seated, leaning forward in a chair, and I found the resident asleep lying over her back with CSF coming out into the syringe so I ended up kicking him in the rear-end. I’m not sure what she [the patient] thought was going on, but that situation really upset me so I kicked him again in the butt, and I said: “Doctor! Wake up! You’re asleep! You have a spinal needle going into that patient!” Well we laugh about it now because that resident went on to become one of the first vascular surgeons at the Mayo and Ochsner Clinics, and LSU, as well as a Dean and Chancellor at LSU. I believe he tells that story whenever he talks about his time in neurosurgery at Charity Hospital.
I was also invited and honored one year by the AANS Spine and Peripheral Nerve Section, and they asked me to demonstrate a physical examination. One of our residents at the time was also going which was good because I could ask him if he would be a candidate for me to examine (because I needed someone who was cooperative). I went through the shoulder, arm and hand, and the audience then wanted me to go through the lower extremity. Well, I guess I got carried away, and I decided to do the buttock in the prone position on a table to show where I would palpate the sciatic notch and make an incision for a buttock exposure. I wasn’t thinking and it was all being televised, and so I drew his shorts down! And the resident yelled “Ahhhh! Don’t do that to me boss!” Which of course showed up on TV and the audience thought that was wonderful, and the resident thought that was just terrible! Which I guess was kind of humorous, but you also have to ask how terrible teaching can get!
Dr. Kline: When I first became Head of the Division in 1971, an early visiting professor was Elizabeth Crosby. At that time, we had a patient who was a taxi cab driver who was robbed by two, I won’t call them gentlemen—they were evil—people, and one of them decided to shoot the driver in the head. That was before they had a window between the front and back seat, and he was brought in as a closed head injury since his cab had gone out of control, crossed the middle of Canal Street, and crashed into a storefront. Well, one of our on-call residents went to the ER and discovered that this man, in fact, did not have a closed head injury. The resident examined him thoroughly and found a hole in his occiput. Subsequently on the skull films, he found a bullet in his brain, and he plotted it out as being in the midline, equidistant from right to left. In fact, it had to be in his pons! The patient had a cornucopia of findings which I won’t bother you with, but rare things like palatal myoclonus, a rare form of nystagmus, and other cranial nerve deficits and long tract deficits. Dr. LeBlanc [the resident] talked me into going to surgery with him and the patient and we took that bullet out of the ventral pons. Afterward, we looked up all of the anatomy and his findings, and we put together a paper with Elizabeth Crosby’s help of survival from a pontine gunshot wound. Over the years, despite his large set of neurologic findings, multiple cranial nerve, and lengthy sensory and motor tract abnormalities, he was eventually able to give some help to a printer whom he had worked for previously when he was not driving the cab.
The second case was a peripheral nerve, brachial plexus one, and it occurred a couple of years later. At the time there was a visiting professor, and he was who the Peripheral Nerve Research Society is named after and who wrote the bible on nerve—Sir Sydney Sunderland. I knew he was coming, and had been referred the son of an internationally known financier. This young man had been a passenger in a vehicle, and had his arm out the window when the driver lost his attention and side-swiped a tree. The patient had a terrible plexus palsy…just terrible. So, I scheduled him at Oschner [Hospital] purposefully when Sunderland was there, and he spent a day in the OR with me (what a God-send that was). What a terrible case. I think at the seventh or eighth hour, Sunderland said “David, you’ve done what anyone could possibly do here. It’s time to stop and not do anymore. You know, there are things that you’re just not going to be able to help.” And, of course, that’s true of all surgery, especially true in the field that you’ve [Dr. Jack] chosen. You must make that a portion of your teachings. I don’t know if I was always good at that, but I tried to remember that wise advice.
Dr. Kline:I think sharing experiences with residents, fellows, and other colleagues and ensuring they all had a good exposure and experience with nerve. Meeting with colleagues and discussing cases also. There were a few of us who started the Sunderland Society and changed it from a study group to a nerve meeting: the first president being Dr. Robert Spinner’s father [Dr. Morton Spinner] and myself being the second, and George Omer the third. I still do some things with that [Sunderland Society] now. Dr. Hackett (former Head of Neurology) and I would sometimes go to the Hansen’s Disease Center in Carville near Baton Rouge which was an unusual experience. I enjoyed it immensely. We would see people with an ulnar and median hand palsy or foot drop from a peroneal neuropathy from leprosy, and sometimes we’d operate on them. Paul Brand, the famous missionary who started the multidisciplinary clinic in Vellore, India, worked there and would call us, and we’d go see people there, but also learn much from him.
Dr. Kline:Well, you know, I think my teaching and sharing my knowledge with fellows, residents, and other nerve surgeons is a contribution. I think mentorship is an important topic, and it’s hard to answer this without seeming self-serving. I don’t make myself out to be the only or best person out there mentoring Nerve either. I don’t think mentorship is something you always decide to do or even the very best ones out there have decided to do. For me, even before we had a NS program, we always had general surgery residents with us. We’d teach them how to do myelograms and pneumocephalograms, as well as head and spine trauma, and did the same for our Oral Surgery residents who were graduates of a combined DDS and MD program. And so, teaching was always something that was present. It’s not easy, and it’s a fine line sometimes. You have to be present for your trainees, but not too present. You have to balance your needs, their needs, and those of the patient. It was hard sometimes to let my fellows and residents work on their own because if you let them, they’ll keep working and do too much. You have to let them work and learn, but you also have to be constantly checking and double-checking them. It’s a fine balance, and you have to have a keen awareness of each individual’s skill-set. It’s like having a medical student examine a patient and tell you what they’ve found, but then you walk into the room and the patient is fully clothed, and it’s obvious the patient has never had their clothes off! Unless you check the student, and teach and show them how to do the exam, then that’s terrible mentorship. You do have a responsibility as a mentor and specialist to teach others and pass on your knowledge about things that are good and work for you so the field can advance. And that does involve publication of papers, chapters, and occasionally books.
We developed operative recordings of NAPs [nerve action potentials] for lesions-in-continuity including injuries, the more benign nerve tumors, and unusual entrapments. We were the first to show that many neurofibromas, whether associated with neurofibromatosis or not, could be successfully resected and that lead-in and lead-out fascicles were usually composed of embryonic axonal tissue (as were those of most benign schwannomas).
Dr. Kline (and wife):“He didn’t…he was never at home.” Well, I guess Nell [Dr. Kline’s wife of 30 years] told you the answer there. Believe it or not we’ve been married for quite a long time, and somehow she’s raised children, held a job, and survived all that. She’s a very, very special person in many ways. I was very, very lucky to have her and two prior wives who were also wonderful in their own ways.
Yes, I worked many extra hours. And we would round on Saturday and Sunday, and we would take turns on weekends and nights. We saw it as our calling; it was a lot of hard work, and being work-crazy helped. The primate center and research center were close which allowed us to take residents and fellows who were on research over there which was important. I instituted research early in their training because I felt as though it was a necessary part of their training. Research was always around in some places, but it wasn’t always at all the other places I worked. I mean I did it, but I was just kind of a funny outlier doing things at night, and on the weekend, and on holidays. And because of that, I probably wasn’t the father I could have been. I mean I tried to be, but not always was. A wise man will be very knowledgeable of the family situation of who he’s trying to be a mentor to and their needs for that, as well as their societal needs. That can be difficult because you’re trying to get your trainees to be crazy like you.
Dr. Kline:Well, I still do some medical related things. I’ll go to some meetings and courses like the Kline Legacy Course, and I do a few things with the AANS and Sunderland Society. Sometimes I write, but I try to let the younger people do most of that. I like to volunteer and mentor still with several different programs. In North Carolina and Louisiana, I belong to Rotary [Club International], and am involved in a number of activities such as the Daniel Boone Native Gardens as a volunteer in charge of [other] volunteers, including individuals who have committed misdemeanors and have to give hours to community service. I serve on the Board for Hospitality House which provides services to the homeless, and for our church in Blowing Rock, I wash dishes and work in the kitchen. When in Louisiana, I do volunteer work through the Covington Northshore Rotary and sometimes for our church, as well as do what work I can on Nell’s “farm.”
What advice would you give to those just starting their careers and trying to foster the kind of success that you have had with yours?Dr. Kline:Of course, I think that triad we’ve talked about of knowledge, clinical work in a specific area and discipline, and research is important. Also, to find a research niche whether that be laboratory or clinical research. In any case, you have to be willing to devote a lot of effort to it. You have to involve other people such as in my case [Drs.] Leo Happel, Dan Kim, Alan Hudson, Bob Tiel, and neurologists [Drs.] Earl Hackett, Austin Sumner, and others. And take advantage of all the resources of your locale, your state, your university, and even your region has to offer. These are all important things.
A personal background and foundation are also important. I had a great background in neuropathology in my training. Knowing what a Masson stain, a silver stain, a Luxol fast blue stain could do helped to get pathology involved in what we were doing at LSU. I had done recordings from nerves at Michigan, Walter Reed, and later at LSU which helped us get more people involved in what we were doing with research and clinical work such as Drs. Happel and Tiel and the neurologists. You have to ask questions. I would ask the lab and pathology people a lot of questions, and get them involved to help and collaborate; and that led us to working out those research and clinical questions. The downside is that research can result in a feeling of letting your colleagues down because you feel as though you’re not carrying your share of the load in teaching and doing enough clinical work, providing night-time coverage, for the holidays, and on weekends. But this is what comes of specialty medicine. I was asked to write about the pros and cons of subspecialization for the AANS newsletter, and the need to balance your subspecialty activities with the rest of your departmental and medical school responsibilities became evident to me during that exercise.
You also really have to accept the fact that you don’t know it all, nor does any individual. Even Sir Sydney! And you have to be very, very persistent at what you’re doing. I don’t know how to say it quite right, but you have to learn to not be the Big Dog even if you are the Alpha Dog. I mean the guy or gal doing the tough aneurysm or head cases. These are extraordinary individuals, but your main goal should focus on excellence in what you do. Maybe that’ll make it harder to be Chair or lead a Department somewhere, but maybe it won’t. Look at some of my fellows and their success without having to act like the Big Dog.
It’s hard to answer this without seeming self-serving. The behavior of being very dedicated to the field that you’ve chosen will result in others labeling you as a mentor. I mean dedicated not only in terms of knowledge, but also in terms of doing—caring for the patients involved and having the ability to share that with the people learning from you. It seems I guess kind of an obvious thing, but not only do you have to be informed, you also have to be constantly open to learning from everyone: residents, fellows, as well as colleagues. At one point, I had formed a sizable mass below my knee in the anterior compartment of my left lower leg. I had seen everyone, and no one could figure what this was. I even had a biopsy and the pathologist didn’t even know what the cells were—“indescribable tissue!” I had a MRI, CT scan, and even a bone scan, and no one could figure it out. Well, one day my fellow [at the time] asked if I had made any progress with it. He recalled reading an article some years before in a journal about the fact that, even though it’s rare, you can get masses of unknown nature related to Lipitor and recommended stopping it. And well I did that, I mean I stopped my medication, and over a period of 5 to 6 months it went away.
Dr. Kline:Of course, I think it’s important to work hard. And like before, be inquisitive and learn the details so as to have a good foundation for what it is you’re doing and passing on to others. You can’t forget the fundamentals and basics like examining the patient.
It’s also important to record your outcomes, and keep track of your patients because that’s how you see what works and what doesn’t. Regardless of whether or not what you find gets batted down by others or not, or you find that over time it doesn’t work, you still have a responsibility to keep track of these things and pass on your knowledge to others for the field to progress.
Dr. Kline:NAPs and intraoperative electrophysiology are relatively newer areas that we started using, and soon became more commonplace. Of course, it relies on having a good physiologist. Electromyography is an area, you know, which most neurosurgeons had not learned very well in their training or career—what it can and can’t do. MRI is also an area that has become more common, and will maybe replace much of electrophysiology and NAPs. But right now, it can only see fascicles [and whether or not they’re in-continuity, not axonal-level detail], although there are nascent studies on axonal maturity and organized observations about whether or not they’re in-continuity and might become functional. To date though, if you were to base your decisions about outcomes and whether to operate solely on some of those observations, you might be wrong. For example, as valuable as ultrasound can be, there can be neurotmetic changes despite fascicles being in-continuity. Maybe some sort of combination of imaging with a functional electrophysiologic aspect to it may replace operative recordings. I think being able to better predict which traumatic injuries and gunshot wounds will recover and which won’t, so that an earlier decision than is possible at present about what kind of operation is needed, is likely to remain a challenge, but one that I fervently hope can be improved upon.
My thanks to my trainees and associates, including my mentors and family, whom with God’s help permitted this professional life to develop. An especial thanks to Line and Andrew for this interview.
I would like to personally thank Dr. Kline and his wife, Nell, for taking the time to talk with me. I do not think that anyone could discuss the importance of mentorship better than Dr. Kline, and as one of the founding fathers from which an entire specialty has grown, nor do I think there is anyone more appropriate or experienced to discuss such a topic. Although I have only met and spoken with him a couple of times, I have already learned so much from him, and consider myself privileged for this opportunity which will surely stand-out for me as a career highlight.
Andrew Jack, MD, MSc, FRCSC