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To cut or not to cut 

A neurosurgeon muses on the advances, challenges in his field.

DAVID REDING: Neurosurgeon.
  • DAVID REDING: Neurosurgeon.
A Little Rock neurologist — Dr. Brad Boop — asked the Arkansas Times to profile a doctor he said is “exceptional,” one who takes time with his patients, one who is “looking to do the right thing for the patient instead of what makes money.” Dr. David Reding, humble almost to a fault, pleaded with a reporter to avoid superlatives when describing him and his practice. He hesitated to simplify for a reporter the intricacies of his work and the talents they require. But hey, it's brain surgery. Reding modestly described his work as not so different from other surgeons' except that “the brain is less forgiving. You have to treat it more delicately.” To operate safely, the neurosurgeon must know the landmarks in the brain's hilly, but identical, geography. He must distinguish between what Reding called the “silent” places — where there's not much going on — and the areas that are running the show. He must move through the soft gray landscape and its rivers of blood and pockets of spinal fluid with the aid of a microscope and a map — an MRI (magnetic resonance imaging) scan. The MRI, the greatest technological advance in his field, provides “beautifully detailed images” not dreamt of 30 years ago when he was a new surgeon, he said. In the 1970s, doctors had to shoot air into the brain's cavities and take X-rays to find tumors, inferring their locations with less than perfect accuracy from suspicious bulges. MRIs have removed much guesswork, fostering better outcomes in brain surgery. Technological advances come with new ethical challenges, however. The brain is sensitive, and unlike other organs, may heal without regaining function. There are times when surgeons can prolong life, but not quality of life. “It's a real dilemma for us,” Reding said. “It's very difficult to decide which cases to treat aggressively because we feel a good recovery is possible and when to withhold because we feel recovery is not possible,” Reding said. If a doctor can save a life, but only at the cost of paralysis and other deficits, should he proceed? “Oftentimes I think we go way overboard,” Reding said. “We patch [patients] up and send back to their families for them to take care of. Often, that's not what the patient would want.” His own father-in-law, he said, “is not very thankful” to have survived, with medical intervention, a stroke he had last year. “We used to put DNR — do not resuscitate — [on patients]. Now, we've changed that to AND — allow natural death. Which has a totally different feel to it,” Reding mused. While he's grateful for the MRI, Reding regrets that the treatment of malignancies has not kept pace with technology. He recalled that Dr. Robert Watson, the state's first neurosurgeon, who took Reding into his practice in 1976, was disappointed that the treatment for malignancies was no better at the end of his career than it had been at the start. Over the course of Reding's career so far, treatment “is marginally better. But the prognosis is very poor.” Malignant tumors may be removed, but they often return. Cures, he said, will come not from the knife but from the laboratory. There's much Reding can do, of course, to relieve pain and symptoms caused by benign growths. He enjoys being able to relieve the “lightning shocks of pain” trigeminal neuralgia causes to the face, and that he can end back pain with surgery. “For the right person, it's fun being able to help,” he said. In his practice, “most outcomes are good.” Advances have also been made in the treatment of aneurysms, weakened arterial areas that, if they rupture, can cause brain bleeds, strokes or death. Radiologists can now insert via the femoral artery a coiled device that, guided to the ballooned-out areas artery walls, will cause blood to clot around its tangles and allow blood to pass the weakened area. “It's an elegant treatment,” Reding said, one that is “much less invasive than what I'd do — dissect down and find the artery and clamp it … ” So is Reding, a surgeon, handing over part of his practice to radiologists and calling it “elegant”? Yes. In the past five years, he said, the device has allowed Little Rock radiologists to safely treat more than 100 patients without a surgical incision. Some authorities still feel surgery is the best treatment, Reding said, and probably it is for some aneurysms. But he hopes endovascular surgery proves as good, because it's less invasive and easier on the patient. Medicine, he said, “is supposed to be about the patient. When a patient comes here to see me, I'm their advocate. And I may advise that they should have some other treatment” rather than neurosurgery. “I try to take myself out of the picture.” So accolades don't make the Fort Smith native comfortable. “I'm a community neurosurgeon,” he said, who works on the most common of abnormalities. Reding drew attention to the “unique skills” that other local neurosurgeons possess. He named Ossama al-Mefty, Ali Krisht, Gazi Yasargil (“there's hardly anybody with a more distinguished career” than Yasargil, he said) and others at the University of Arkansas for Medical Sciences and in the community. Just in the past month, Reding said, he's sent two rare cases more suited to their talents than his UAMS. With Reding, it's all about what's best for the patients.
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