When you think of an operating room, you likely envision a sterile environment with sanitized equipment, the low beeps of a heart rate monitor, and the subtle crunch of a plastic gown over the surgeon’s scrubs.
What you likely don’t expect to hear are the dulcet tones of a saxophone.
But for doctors at the University of Rochester Medical Center, last summer the sweet melody from Dan Fabbio’s woodwind instrument was a welcome sign of a successful surgery.
In spring 2015, Fabbio, a music teacher in New Hartford, N.Y., started experiencing hallucinations. He felt dizzy and nauseous, too.
For the 25-year-old musician, these symptoms were alarming.
He decided to visit a nearby hospital and underwent a CAT scan. The doctors there found a mass in Fabbio’s brain.
“I was 25 at the time, and I don’t think there is any age when it is OK to hear that,” Fabbio the University of Rochester Medical Center. “I had never had any health problems before, and the first thing my mind went to was cancer.”
Fortunately for Fabbio, the tumor wasn’t cancerous. What’s more, the tumor was easily accessible to surgeons.
However, the tumor was in an area doctors knew was important for music function.
Even though it wasn’t cancerous, the tumor was still a threat to Fabbio’s livelihood.
Operating on a musician’s brain
After receiving the news, Fabbio met with Dr. Web Pilcher, the chairman of neurosurgery at the University of Rochester Medical Center.
Recognizing the importance of removing the tumor without impacting Fabbio’s musical abilities, Pilcher knew he had a special case on his hands.
Pilcher called on Bradford Mahon, PhD, a cognitive neuroscientist, associate professor in the University of Rochester department of brain and cognitive sciences, and the scientific director of the University of Rochester’s Program for Translational Brain Mapping.
“We study about 40 patients a year [at the Program for Translational Brain Mapping] in the same way that we studied Dan. We have a series of tests that we run all the patients through that map core abilities like language and motor function and memory,” Mahon told Healthline. “Then we also look at the anatomy of each patient’s lesion, if it’s a tumor, or even if it’s not a tumor. We look at the anatomy of where the neurosurgical intervention is going to take place. We talk to the surgeons about what is their likely approach to address this issue in the surgical context, and then we look at the patient’s broader life interests, hobbies, and profession. We ask what functions that are really important to this patient might be located adjacent to or involved in the intervention. In Dan’s case, that was very clearly music.”
Testing the language and motor skills of patients is standard practice in brain surgery, but for Fabbio, the risks of damaging the part of his brain responsible for music meant doctors needed tasks they had rarely considered before.
So Mahon called on another University of Rochester colleague, Elizabeth Marvin, PhD, a professor of music theory at the Eastman School of Music, who also works in the department of brain and cognitive sciences and studies music cognition.
Marvin developed several musical tasks for Fabbio, including listening to brief melodies and humming them back during fMRI scanning.
The two musicians also developed a modified form of a song for Fabbio to play during the surgery.
“Based on the scientific literature, this task triangulates what we believe, in combination with Dr. Marvin, to be core to music ability,” Mahon said. “Dan completed several hours of functional MRI in which we mapped music processing using this particular melody repetition task. The data indicated that, in fact, as we had supposed prior to even studying him, this core music ability was located directly adjacent to the tumor, and that any surgical intervention to remove this tumor should take into account the critical role that the structure had for supporting musical ability so that the ability could be preserved and the tumor could be removed.”
With their plan in place, Fabbio underwent surgery in August 2016. During the hours-long surgery, the surgeons and medical team woke him up from his medically-induced sleep.
They asked him to perform the same melody repetition tasks he had performed prior to the surgery to check for changes in his abilities.
For the final and ultimate test, they handed him his saxophone.
“The most assured way to know that his music abilities would be intact would actually be to have him play his instrument in the operation,” Mahon said.
The team held their breath. Soon came the woodsy tones of an alto saxophone playing “Arirang,” a Korean folk song.
“He played the song beautifully,” Mahon said. “It was one of those wonderful moments that you realize everything that you had done had fallen into place, and he still has his music abilities intact, and his tumor is removed, and it’s time to move on with the surgery, and everything has been successful.”
For three to four weeks after the surgery, Fabbio struggled to find the right pitch and match two notes, definite challenges for a music teacher.
However, his full musical abilities soon returned, just in time for him to begin a new season with his school’s marching band.
The future of brain mapping and surgery
Perhaps it’s the work that Mahon and Pilcher did before the surgery that is the most unique and most promising aspect of Fabbio’s surgery.
After all, awake craniotomies are not new. They’ve been used regularly for the past two decades, Mahon said.
But the use of brain mapping — that is, figuring out to a specific degree what areas of the brain are responsible for specific tasks — holds a lot of promise for future brain surgeries.
“The goal of any brain surgery is to solve the problem that’s at hand without creating a new one,” Dr. Michael Schulder, director of the Brain Tumor Center at Northwell Health’s Neuroscience Institute in New York, told Healthline. “In the case of a brain tumor surgery, you want to take out the tumor without making them worse.”
With speech and movement, surgeons have ways to stimulate the brain to perform those tasks without waking a patient up.
But for higher cognitive functions — language, memory, thought processing, or even the ability to play music — doctors need patients to be awake.
That’s what makes Fabbio’s surgery — and ones like it — so unique.
As doctors understand in greater detail how the brain works, the ability to save or restore important capabilities grows increasingly possible.
“The tasks should be tailored to the area that is at risk or the function that is at risk,” Schulder said. “I recently had a patient who is an electrical engineer, and his main concern was not being able to deal with circuit logic problems. My neuropsychology colleague studied circuit logic, and that’s primarily what we tested him on during the surgery.”
“Because local anesthetic is applied around the point of incision and because the brain itself has no nerve endings, patients are very comfortable,” Mahon said. “Except for the ergonomic constraints of the surgery itself, they’re physically very comfortable. They can then be alert and participate in any cognitive task the surgeon deems to be clinically relevant for mapping functions that need to be preserved in order to remove a tumor.”
In the future, doctors may be able to test tradespeople and craftspeople, musicians and hair stylists, makeup artists and writers, to make sure tumors are removed without sacrificing their livelihoods and passions.
Will a paint brush and canvas replace the saxophone in a future operating room?