Screws and rods don’t really seem to belong inside the human body. Shiny titanium, dripping blood, protruding from ivory bone like an alien’s appendage: weird, right? The internal fixation of vertebrae certainly has its proper place in the surgeon’s armamentarium, though. Especially in the never-ending battle against tumor, trauma or spinal degeneration.
A good screw, a well placed screw, is part of a construct; firmly securing (forevermore) two or more vertebrae. A good screw needs rock-solid purchase in the bone. A perfect screw is a good screw with the added benefit of looking pretty on the X-ray.
The screw I’d just implanted was good, really good, not perfect though. It took a weird angle on the way through the bone. It was U-G-L-Y (didn’t have no alibi).
It’s so tempting to remove an otherwise good screw, if it’s ugly on the X-ray. I know I’ll be shooting X-rays every time the patient comes to the office for follow-up. That funny looking screw will be staring me in the face for years to come.
“Perfect is the enemy of good,” I said.
I sewed up the incision, burying the ugly screw under the patient’s beefy paraspinal muscles.
Like any experienced carpenter, I know that if I fiddle around with the damned thing too much (remove, redirect, reimplant, repeat), I’ll end up with a supermodel X-ray, but hardware that’s slightly loose. If a screw has too much play it can wiggle free over time.
“Better for me to be taunted by an ugly X-ray for the next twenty years, than for the patient to need another surgery in six months.”
Perfectionism may lead to bad decision making.
For some people, despite knowledge that a perfect performance isn’t always attainable, even the smallest imperfection may lead to severe discontent. In extreme cases, this may be accompanied by depression, eating disorders, obsessive compulsive disorders, psychosomatic syndromes and anxiety disorders.
In 2017, a consortium of neuroscientists from Australia and Germany reported on brain activity in maladaptive perfectionism. The scientist recruited 80 volunteers to participate in their study. They administered a questionnaire: The German version of Frost’s Multidimensional Perfectionism Scale, which measured agreement with such positive statements as ‘I am very good at focusing my efforts on attaining a goal.’ On the dark side, maladaptive perfectionists agreed most strongly with statements like, ‘The fewer mistakes I make, the more people will like me.’
The volunteers were subjected to a game designed to induce mistakes. Participants completed a task where stimuli (three white digits on a black background in the center of the display, e.g. 242 or 343) were presented on liquid crystal display goggles. The participants responded differently depending on whether the central digit was odd or even. The test was performed while the participants’ brains were evaluated with fMRI. Errors provoked brain activity in widespread areas of the brain in all participants, an error processing network. These areas included wide swaths of the frontal lobe (part of the brain that controls executive function), the insular cortex (part of brain that has important roles in sensory processing, decision-making, and motor control) and dorsal striatum (caudate and putamen nuclei (areas that modify movement) and hippocampus (an area involved in emotion and memory).
The brain activity had a unique aberration in those individuals with maladaptive perfectionism. Errors committed by these individuals seemed to shut down the medial orbitofrontal cortex (executive function area of the brain, responsible for attention, concentration, self-control and decision making), and strongly activate anterior cingulate cortex (an area involved with emotion, learning, and memory) differently. These brain findings, along with behavioral findings during the study, led the researchers to conclude that, after an error commission, maladaptive perfectionists processed the information in a personally destructive manner.
In 2017, scientists from Southwest University, China studied brain anatomy in maladaptive perfectionism. They recruited 161 volunteers and performed MRI studies to determine the brain volume of various regions. The researchers identified maladaptive perfectionists (excessively high performance standards, disabling worry about making mistakes, and excessively doubting actions, anxiety and depression) with a version of the Frost Multidimensional Perfectionism Scale, which is specific to Chinese culture. In maladaptive perfectionists there was a greater gray matter volume in the anterior cingulate cortex. This reinforced the findings of the fMRI study performed by the German and Australian scientists.
Iranian researchers, in 2015, investigated the brain regions that may be structurally correlated with maladaptive perfectionism. They analyzed brain MRIs of 49 participants. The researchers gauged their levels of perfectionism using a scale different from the previously discussed groups of researchers. In contrast to the Germans, Australians and Chinese, they reported that the maladaptive perfectionists had altered gray matter volume in the thalamus (the main relay hub for the central nervous system) and the back part of the left parietal lobe (part of the brain that integrates various types of sensory information).
Even after they’ve achieved ninety-nine percent of their goal and pushing for that last one percent threatens to bring everything down around their ears, maladaptive perfectionists don’t know when to quit. They can’t be satisfied when something is good enough. They tend to keep pushing and pushing until they snatch defeat from the jaws of victory. It’s OK to be somewhat of a perfectionist on many occasions, especially when there’s important stuff on the line. But good decision making demands that you acknowledge that perfection is simply not attainable all the time and behave accordingly.
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I have similar screws in my spine for scoliosis….