Joel Winer, M.D.:The Practice of Neurosurgery

Joel Winer, M.D.

Just before Dr. Winer was to start medical school his then-brother-in-law “fell off a cliff” and was severely brain-injured. After the “dominant-hemisphere” injury he was hospitalized for a year and was non-communicative. I struggled to listen as the doctor quietly told me this sad family story. "It was a long drawn-out process,” he said, “and he ended up being institutionally supported for the remainder of his days, which was until, maybe, five years ago.”  Dr. Winer admitted that "subconsciously" this may have influenced his career choice...but he's not sure.

Dr. Joel Winer is an ever-so-slightly-graying but still boyish neurosurgeon who has served the York community for nearly 27 years. I asked him how the serious and often life- and personhood-threatening problems he sees nearly every day affect him. Does he, say, discover that he is more grateful for what he has?

After a short pause, he answered, "Neurosurgery is a microcosm of life. There are ups and downs, and you have to celebrate the ups a little more. That works for me. You complain less about the little things. A flat tire becomes less important." 

A Hospital in Honduras

Continuing his thoughts, "The privilege of being a part of medical missions in Honduras for a number of years also gave me a good perspective about what we take for granted and what we should be more grateful for. We wander through the day, not realizing that tomorrow may be the day we have a problem." 

"Life hangs by a thread," I offer.

"It's fragile. We all have these elements. When someone comes in with a brain tumor diagnosis (for example) they are losing direction. We all have a piece of that, because of the uncertainty of life. So, if we can help one another, instead of (following) Western hemisphere competitiveness, it could be better," he softly explained. He went on, "Growing older, we learn a lighter footstep than when we were younger. We try to do the best we can."

"But it seems that many parts of your practice could be so depressing," I say.

A quote from Viktor Frankl

"I think that," he noted wryly, "depending on your existential perspective, life can be depressing. For me, neurosurgery is life. The basis of humanity is that we can make a good thing happen. Sometimes (when things are dark) it's hard to see that humanity is going to win out. At base we have to be good, otherwise, we are not going to continue to exist...(and) we do better together than individually." 

As we talked further I was moved by his clear and balanced optimism about life despite what he has seen and what he does. "You might be one of the happiest doctors I’ve met," I blurt out, without thinking. 

"Maybe I am just a happy person," he responded, with a smile, and a laugh.   

Location of Niskayuna, NY

Dr. Winer is originally from a little town in upstate New York just east of Schenectady called Niskayuna (the Mohawk word for "extensive corn flats").  

[Wikipedia notes that William Edelstein, one of the key developers of MRI, the technology that has changed neurosurgery forever, lived in Niskayuna, too. But more on that later.]

His dad, a retired optometrist, who will be 90 in July, was the only member of his family who went to college. He is "one of the nicest men on the planet," according to Dr. Winer, and when his patients couldn't pay for their care he understood, and just let it go. 

When his father became “bankrupt” he joined another optometrist, this time as an employee. After one of their patients complained that their eyelashes were hitting their new glasses the guy he was working for said "close your eyes" and simply trimmed the offending curved hairs. Shocked, Dr. Winer’s father said to himself, "I'm out of here," and he left. He then opened a practice of his own in the small textile-manufacturing town of Cohoes (Mohawk for "place of the falling canoe"). 

Dr. Winer's mother is 88 and is a "wonderful" wife and mother who, after raising her three sons, did real estate and was a school guidance counselor. His older brother is an accountant and his younger brother is an electrical engineer.

The happy youngster wanted to be a doctor, even in high school, and Dr. Winer left New York to begin his studies. After receiving his undergraduate degree in nuclear chemistry from the University of Maryland at College Park he went further south to Tulane for medical school. He then came back north again and did a grueling neurosurgical residency at Temple in Philadelphia under Dr. William Buchheit, "a terrifically tough fellow."  

National Hospital for Neurology and
Neurosurgery, Queen Square

He then went east (really east) and did a classic neurology rotation at the National Queen Square Hospital in London. This was followed by a trip north (far north) for a fellowship in seizure surgery at the Montreal Neurological Institute with the epilepsy pioneers Drs. Andre Olivier and Theodore Brown Rasmussen. 

He considered academic medicine, focusing on surgery for epilepsy (he was signed up to do a fellowship in Connecticut and at the last minute changed his mind), but decided that such a practice was not for him. He was better suited, he thought, to be a general neurosurgeon, and to be able to make it to his kids' soccer games. After this hard decision was made he “never looked back.”

So, how did Dr. Winer then go a little bit west to wind up in York in 1991? Well, one of his now-retired partner's sons was a medical student (now also a neurosurgeon--go figure) who rotated on the Neurosurgical Service at Temple. It was about time to look for a practice and Dr. Ron Paul's son said, "Why don't you come and look at my dad's place in York."  

York? He would consider the idea. Since his wife is from Palmyra, just outside of Hershey, he toured the practice and liked what he saw. Despite his previous travels, he noted that "We always (aim to) settle within, you know, 100 miles of our in-laws." So he joined the group and has stayed here since.

Russian Cossacks on the March
(Carl Ernst Hess c.1800) 

Speaking of his wife, Dr. Winer admitted that when they were younger she used to refer to him as “the rebel.” He explained to me that this trait “may be cultural." His grandparents were from Odessa, Kiev, and Warsaw. They were Eastern European immigrants who “survived because they fought.” Sometimes his grandmother wondered "why we were not rioting in the streets." Dr. Winer reassured her that she was safe, that “the Cossacks are not coming over the Urals.” 

I wondered if he recalled any particularly moving or memorable patients that he’s taken care of over the years.

Memorable patients? He thought for only a few seconds before he said, “One who just got married.”  Dr. Winer had met the newlywed from Honduras in 2010 when the patient had a “dorsal midbrain lesion” (at the back of the all-important brainstem) and was referred here for treatment. Dr. Winer had arranged for all of his intricate coordinated care to be donated. 

The young patient did "terribly well," but years later had a “shunt malfunction” and returned to York. The “rebel” surgeon and Dr. Robert Schlegel (one of his partners then) "agonized" for several days over what to do. Could they help the man again without doing harm? They struggled, and finally operated. “The patient came through it...mercifully.” And “it was probably more than me at hand,” he believed.

Another especially memorable patient had a glioblastoma, the most malignant of brain tumors, with an unusually prolonged remission. For reasons he admitted he didn’t understand, “the darling fellow went 11 years (without disease) before his tumor came back.” He then added, ”When we have that rare long-term survivor we don't know why, and we celebrate when they come in.”  

He feels that medical science often progresses by serendipity and that  the answer for glioblastoma “will come in a very left-field way." While there have been advancements in supportive care for these patients such as more precise surgery for non-dominant hemisphere lesions, effective adjuvant chemotherapy, and advanced radiation protocols, “we still don't (fully) understand the biology.” But we are getting closer. 

“What major technical advances have you seen in the past 30 years?” I asked.

(Time for a few tidbits of neurosurgery and brain imaging history.)

Trepanning  c.1350 (Getty Images)

[There is good evidence that holes were drilled in skulls more than 5,000 years ago (and that at least some individuals survived this so-called trepanning to, maybe, release the evil spirits), but operating on the brain was dicey until modern neurosurgery began with Dr. Harvey Cushing at Johns Hopkins at the turn of the 20th century. However, they were still “in the dark.” Without any way to image what was going on in the brain before sawing open the skull, the surgeon made a preliminary diagnosis based entirely on a meticulous clinical history and a detailed physical examination. 

This usually allowed him to “localize” the lesion and make an informed guess about the cause of the problem, but he could be surprised and the actual lesion could only be confirmed by seeing it.  X-ray (though in use since 1895) was of no help with the “soft tissue” of the brain and spinal cord.

So in 1919, Dr. Walter Dandy at Hopkins came up with (dare I say) a “dandy” solution; the spinal fluid was drained and replaced by air. This allowed better contrast between the brain tissue and surrounding or internal structures by plain x-rays. The patient was immobilized strapped to a chair and twirled around into different positions to get the pictures. It was, needless to say, not well tolerated, and it was “indirect.” This pneumoencephalogram, as it was called, was still used into the 1970s! 


Another indirect way to see what was occurring in the brain was devised in 1927 by the Portuguese neurologist Edgar Moniz. He injected dye straight into the carotid artery (ouch) and took a rapid series of x-ray pictures of the blood vessels. This “angiogram” showed displacement of normal landmarks, and any abnormalities of the vessels themselves, but not the actual tumors or other masses. Again, it was partly a guessing game for the brain surgeon. 

Left carotid angiogram (from NeuroradialAccess)

The breakthrough came in the early 1970s with the CT scan, invented by Godfrey Hounsfield in 1967 at the EMI lab in England. The science evolved rapidly and the first MRI images of a human were published in 1977 (the scan took five hours). Since the late 1970s both CT and MRI have improved spectacularly.]
(Back to Dr. Winer.)

"I can't imagine practicing surgery in the 1950s when the giants in neurosurgery were laying the foundation. We stand now on their shoulders." Dr. Winer said.

MRI Spectroscopy of 2 tumors (From Franklyn Howe)

He notes that MRI and MRI “subsets” such as MR angiography (to be able to see arteries without the danger of catheters), MR venography (to visualize the draining veins of the brain), MR spectroscopy (to image metabolic activity to distinguish tumor from an abscess, for example), and cine-flow (to watch the flow of spinal fluid) have revolutionized his beloved specialty and have made tricky brain and spinal operations much safer and remarkably more precise. 

In addition, there have also been key advancements in neuroanesthesia, and there is the emerging technique of “computer-directed surgery.”  With the electronic health record “they can read my (poor) handwriting,” he noted, “(and) my history and orders are accurate and immediately available (across the health system).”

Site of temporal lobectomy
(From Mayfield Clinic)

What procedures does he especially like to do? Temporal lobe resection for uncontrolled epilepsy is particularly rewarding, as seizures often stop occurring or are more easily controlled. He is also happy to be able to alleviate back and leg pain by doing a discectomy and lumbar fusion, or to relieve neck and arm pain or spinal cord compression by cervical disc surgery. Removing a benign and superficial “convexity” meningioma is also very rewarding. Implanting electrodes for so-called “deep brain stimulation” for Parkinson’s disease relieves tremor and other abnormal movements but, regrettably, he noted, does not stop the progression of this debilitating disorder. 

With the “interventional” vascular expertise of one of Dr. Winer’s new partners, aneurysms and vascular malformations can be treated definitively without craniotomy, without exposing the brain to the air. And the damage caused by a clot blocking a major artery can be reduced by removing the thrombus, even 24 hours after the onset of the stroke.

So, what do we see in the future? Tomorrow's neurosurgeons need to integrate information technology with the evolving advances in imaging, molecular biology, and genetics. Surgery itself will become even more focused on minimally invasive techniques and will increasingly use digital technology. True team efforts will be more important than ever. Today’s intractable problems will be less so. 

Hyper-SCOT Decision-Making Navigational 
System (Okamoto in Biomedical Engineering 2017)

Hours after the interview ended, later that evening, my husband pointed me to an article on Medscape: “The Inexplicable Irony of a Future Neurosurgeon Losing His Father To Brain Cancer," by David Kurland, M.D., Ph.D. 

My eyes took in the faces in the photo beneath the title. A mother, a father, and a son smiling together on their porch. I wanted to stay with this image. I did not want to read the story, but I did. A just-graduated medical student had received the “match” for his longed-for seven-year neurosurgical training. Soon after, he learned that his father had a deep-seated aggressive and, therefore, non-surgical brain tumor. Sadly, there was nothing to do, and his father died several weeks later. 

Surrounded by friends and family he put his father to rest. Shortly thereafter, as had been planned, he celebrated by marrying his beautiful fiancé. 

Celebrate the ups. Celebrate life. Because, yes, it really can change in a moment.

An update on a possible treatment for glioblastoma (from MedLinx 7/26/19):

Neurosurgeons at Massachusetts General Hospital crafted a CAR-T cell that can be delivered into the cerebrospinal fluid. When it gets into the brain, the CAR-T then secretes a second type of immunotherapy, called a bi-specific T-cell engager, or "BiTE." This" can have a local tumor effect by targeting the second tumor antigen. In an animal model of glioblastoma, they found that the modified BiTE-secreting CAR-Ts eliminated about 80% of the tumors. The technique holds promise for treating other solid tumors as well, says lead author Bryan D. Choi, MD." 

(Read the most recent story here.)