TMC PULSE

t m c » p u l s e | n o v e m b e r 2 0 1 6 13 I remember when I first met with the neurosurgeon, I said, 'I'm not here to just be cured, I'm here to get well enough to live out my life doing what I love.' — CLAUDIA MARTINEZ McGovern Medical School Student Diagnosed with Chiari Malformation Depending on the severity of symptoms, treatment often includes a surgical procedure called posterior fossa decompression. This involves removing part of the back of the skull and a small portion of the first cervical bone to give more space for the cerebel- lum, and then adding a patch to expand the dura (the covering of the brain). For most, multiple brain surgeries and the extensive rehabilitation and recovery process that goes along with them would be more than enough to fill the 1,800-plus days since Martinez's initial diagnosis. But this patient is differ- ent. Described by her mother as the strongest woman she knows, Martinez refused to let these setbacks steer her off course. Not only did she manage to complete her undergraduate degree— the first in her family to do so—but she is currently wrapping up her second year at McGovern Medical School at UTHealth. All this despite yet another health emergency this past July that left her hospitalized and barely able to move for weeks. Tethered It was early summer and Martinez was finally enjoying some stability, waking up early to memorize tumor histology and staying late at the hospital to work on a research project with one of her mentors, Dr. David Sandberg. "I didn't know much about her med- ical history and I didn't feel it was my business to ask," said Sandberg, chief of the division of pediatric neurosur- gery at McGovern Medical School and a practicing neurosurgeon affiliated with Children's Memorial Hermann Hospital. "She was working with me on some research and she was extraordi- nary in that capacity—very bright and hardworking and determined." But then, very much out of char- acter, Martinez was suddenly absent without explanation. "I remember emailing her to check in, just to see if everything was OK, and she told me she had been admitted to the hospital," Sandberg recalled. "I was shocked." It turns out that over the course of the previous months, Martinez had lost nearly all muscle control in her pharynx and esophagus, making it extremely difficult to swallow. After choking on her food several times, she drastically reduced the quantity and consistency of food she allowed herself to consume. Determined not to be derailed in her studies yet again, she focused on school and kept mum about the issue. Eventually, the lack of nutrients in her body landed her in the emergency room. An extensive GI workup revealed nothing, so her physicians, aware of her surgical history, turned to brain imaging. The tests were inconclusive, but results from her MRI did show something unusual: her brainstem had become tethered to the dura, pulling it sharply to the right when it should have been floating freely in cerebrospinal fluid. Because the brainstem plays an intricate role in the act of swallowing, the question loomed: was this the cause of her choking? "My opinion was that I wasn't sure," Sandberg said. "It was compelling enough with the brainstem being pulled so much that if no other cause could be found, I recommended surgery to untether the brainstem, which is an unusual operation." Just beginning In a serendipitous chain of events born out of timing, expertise and old-fash- ioned goodwill, Sandberg, who typically only operates on children, agreed to perform the surgery. After freeing the brainstem from the dura, his team per- formed a duraplasty using Martinez's own pericranium as a tissue graft to increase space for the brainstem to float inside the skull. It worked. After months of recovery and rig- orous rehabilitation at TIRR Memorial Hermann, Martinez has once again developed sensation in the back of her throat and is slowly regaining a normal gag reflex. She has relearned how to walk and, thanks to an accommodating group of administrators and professors at McGovern Medical School, is catch- ing up on her coursework at home. She even managed to find time to organize her annual Chiari malformation aware- ness walk. Working with the national organization Conquer Chiari, Martinez raised more than $30,000 this year and has singlehandedly created a local support network for individuals in the Houston area diagnosed with the condition. "She just keeps working; you can't get her to stop," Sandberg said. "She's just so determined to not let her condi- tion impede her goals." Martinez and her physicians hope this will be her last surgery, which means a clear road ahead for her to become a pediatric neurosurgeon herself. "I've wanted to become a doctor since I was little, but I obviously didn't expect to become a doctor by being a patient this entire time," Martinez said. "Going through this made me even more certain that this is what I want to do. A lot of people are diagnosed with illnesses and they think it means their life is over, but I believe some- times in those diagnoses your life is just beginning." Left: David Sandberg, M.D., holds a printout of Martinez's MRI taken prior to her surgery this summer. Martinez, in her white coat, takes in her reflection in a full-length mirror.

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