Still on operating table, patient plays sax to show surgery was success

You feel music in your heart and in your soul, but where does it live in your brain?

Using a type of magnetic resonance imaging that allows scientists to map the brain as though they were pinpointing cities in an atlas, a team of music and medical experts at the University of Rochester isolated the area to avoid while doing surgery for a benign tumor.

To confirm their finding, they had the patient, music teacher Dan Fabbio of Oneida County, play his saxophone while he still was on the operating table.

The surgery took place over a year ago but the findings were published in August in the journal Current Biology.

Dr. Webster Pilcher, chairman of the Department of Neurosurgery, said the surgery adds to brain science by narrowing the area of the brain where music resides and showing that functional MRI can reliably indicate where activity occurs in the brain.

The idea of someone being awake during brain surgery sounds utterly offputting. But the procedure has been done for years. This procedure grabbed attention because of video of Fabbio lying on his side on the operating table and under surgical drapes, blowing the notes after the tumor was removed but before his skull was closed.

“It was a beautiful moment,” said Brad Mahon, part of the team that prepared Fabbio and monitored his progress in the surgery. “The tumor was removed at that point, and he was playing the saxophone gloriously. We knew we had done something special.”

Fabbio was not available to talk about the procedure, but Mahon, Pilcher and Betsy Marvin of the Eastman School of Music described the surgery.

Busy brain chugs oxygen

When you’re doing a specific task, the area of the brain responsible for that activity uses more oxygen. For example, reading this article is stimulating the part of your brain that processes the written word. If you were to read this while undergoing a functional MRI, the image produced would show heightened activity in that region — as if you were using an infrared camera to see the heat escaping from your house.

Areas that govern particular activities are more or less in the same place in everybody. But the precise location for one person can vary by a couple of centimeters from someone else. That is a huge difference in brain surgery.

“You can’t just look at the brain and know in a given individual exactly which region is carrying out which function," said Mahon, who holds a doctorate in psychology. "You have to do some kind of brain mapping."

Mahon is scientific director for UR’s Program for Translational Brain Mapping, which uses functional MRI to create personalized brain maps of patients. That way, surgeons know the exact terrain of each individual’s brain. The mapping is done on patients with benign and malignant tumors, on patients with epilepsy and on patients with congenital malformations of veins and arteries that could lead to stroke. The goal is to protect areas responsible for language, movement, sight, hearing and other skills while fixing the problem.

About 40 patients a year undergo such tests. The timing is dictated by clinical urgency, and for some, they happen over a matter of days. For Fabbio, the seven hours of MRI tests spanned about six months. He lay in the MRI tube as images were captured of him repeating sentences and humming snippets of tunes he heard on a piano. 

Those images were displayed in the operating room, where Mahon ran the same cognitive tests on Fabbio as before the surgery. “We were the bridge between the patient and the surgeon,” he said.  

No, not that spot

Awake brain surgery has been done since the middle of the last century. Pilcher has been doing the procedure for more than 20 years. The patient is sedated, similar as for a colonoscopy, while the skull is opened. Then the patient is awakened for the procedure in order to communicate with the surgical team.

For the past few years, Pilcher and Mahon had been working to bring functional MRI images into the operating room. They did brain mapping on an accountant and a furniture maker, and both emerged from their surgeries with their individual cognitive gifts intact. Pilcher said brain mapping allows surgeons to work with more precision so they can preserve functions that give meaning to their patients’ lives. 

Pilcher said the medical literature has reported the general area of the brain where music resides, but the brain mapping provided the opportunity to find specific locations. With Mahon prompting Fabbio with sentences or music, Pilcher used a mild stimulating probe on Fabbio’s brain as he repeated what he heard. If Fabbio misspoke or didn’t hit the tune, Pilcher knew he had to stay away from that area.

Humming in key

Betsy Marvin had never been in an operating room. Upon entering, she first watched the procedure on a monitor. But the professor of music theory at UR’s Eastman School of Music had to be alongside the medical team.

“My job was to listen to him singing back those melodies and to say whether it was correct or not,” Marvin said. “There were a number of times when it was unclear and the doctors looked back to me and would you say that was right or wrong. In real time I was having to judge is this OK is this not OK. That’s kind of challenging to do. Here he is, halfway knocked out and lying on his side and in the middle of surgery. Of course he’s not going to sing everything perfectly in tune.”

Marvin had been involved from the beginning. She teaches a course called Music and the Mind, and her interest in the brain brought her in contact with Mahon long before this surgery.

Like Mahon, she spent hours with Fabbio prior to the surgery. During one of those sessions, the idea came up of him playing the saxophone after the tumor was removed — the coda to signal that all had gone well.

It would have to be something he already knew. Marvin saw one of the nurses react as Fabbio played some notes.

“It was clear she was becoming alarmed,” Marvin said. “She said, ‘You can’t play that piece. There are too many long, sustained notes.’” Fabbio would be playing the sax with part of his brain exposed, and blowing so much air would put pressure on the tissue and make it protrude. So Marvin and Fabbio altered the piece so it had more rests and breaths. 

Marvin described the exhilaration of hearing Fabbio play.

"I was very grateful to Dan for undergoing all this," Marvin said. "Months and months of testing and practice. I thanked him for going through all this. He said, 'Of course I would do this if there is some chance this would preserve my musical ability, why wouldn't I?'"

PSINGER@Gannett.com