Is technology always necessary in the operating room? Here’s what a neurosurgeon thinks
Technological and robotic advances in surgical interventions are allowing for enormous progress in spinal and cranial operations, making operations easier for surgeons and offering patients safer options that reduce the risk of complications and speed up recovery.
In addition, technological advances allow us to perform surgeries in a minimally invasive manner by accurately knowing the anatomy through planning, navigation or augmented reality before operating on the patient.
With minimally invasive approaches, we perform surgeries with smaller incisions, with less muscle or bone tissue injury, less blood loss, the risk of infection is lower and recovery is faster due to less postoperative pain.
However, all these advantages will not be enough if we are not able to achieve the objective of the surgery, which, when we talk about the spine, can range from optimal decompression of one or more nerve roots to achieving a good lumbar fusion thanks to an appropriate surgical technique.
Technology will also help us with preoperative planning, which is of vital importance. In addition, we will be able to know exactly, in advance, not only what we are going to encounter, but also to be able to estimate what the result will be depending on the technique we choose.
One of the great advances in medicine and surgery has been the great progress and development experienced by diagnostic imaging methods. The image quality and the detail of the anatomy achieved with current MRIs and CT scans is nothing like what we had just a couple of decades ago. Other types of tomography have been added to these diagnostic pillars, such as positron emission tomography (or PET-CT) that allows us to monitor tumors and the differential diagnosis of infections in the spine, or SPECT-CT (single photon emission computed tomography) that allows us to diagnose bone lesions of a spondyloarthritic, metabolic or traumatic nature.
But in the spine, it is EOSedge precision teleradiography that allows us to scan the spine from head to toe using two beams that run in parallel and with a radiation dose six times lower than a conventional X-ray. With the global image of the spine, we have learned that each of our spines is very particular, even if we try to group them into four large groups according to the spinopelvic angles. What we do know is that this information is of vital importance when we talk about operating on a patient, especially if the intervention to be performed is a lumbar fusion or arthrodesis. Given that, in this type of surgery, one segment (or several) of the spine will be fixed, it is extremely important to respect the shape of the patient’s spine. Even so, our spines move continuously. We must consider that just by going from a sitting position to standing, we go from little or no lordosis when sitting to significant lordosis when standing.
The other great advance experienced in spinal surgery in recent years has been the improvement in materials. Biocompatible materials have been achieved that, through surface treatment technology, adapt better to the vertebral bone, with the consequent decrease in the number of complications by drastically reducing the percentage of implant failures in our surgeries. The evolution of materials has also allowed us to progress in the safe use of more physiological implants such as disc prostheses, which, unlike fusions, allow movement of the vertebrae between which they are housed.
Furthermore, nowadays, some implants can be made to measure for the patient. It is true that this entails an increase in cost, but they are necessary, for example, in complex surgeries with long instrumentation in cases of scoliosis. Custom-made bars have simplified these interventions, reduced their time and, above all, thanks to preoperative planning, have allowed us to estimate the best and safest corrective result for the deformity that these patients present.
In addition to implants, intraoperative monitoring measures have also improved significantly, both for overall patient management during neuroanesthesia and for intraoperative neurophysiological monitoring. Continuous monitoring by recording nerve structures during the intervention alerts us and prevents potential neurological injuries that may occur in spinal surgery or brain surgery.
Intraoperative O-arm 2 or LoopX scanners allow us to capture images of patients in real time and position. Images that are transferred to a computer station allow us to navigate and place our instruments with the greatest precision. In this sense, robotics applied to spinal and brain surgery has meant a great evolution, especially in the field of functional surgery (movement disorders and epilepsy). In the spinal column, the Mazor X robot, after a preoperative planning that we can carry out on our laptop the day before at home, accurately executes the planned trajectories, allowing us to place our instruments and implants with the utmost safety through the robotic arm. Intraoperative scanners also allow us to confirm the correct placement of the implants before the patient leaves the operating room and, in cases of tumor surgery, to confirm that the degree of resection is as high as possible. This way, we avoid reinterventions and improve the degree of survival.
Intraoperative imaging systems have also recently improved greatly. Endoscopy applied to spinal or brain surgery offers image quality and detail that was unthinkable a few years ago. We are seeing that with these small optics we can perform pituitary tumor resections better than before, that we can better resect tumors or tumor remains hidden in recesses in skull base surgery, and that there is less tissue damage in the spine, less postoperative scarring and therefore less chance of suffering from postoperative radiculopathy.
But all this technology will not be useful to us if we are not adequately and sufficiently trained. In fact, in very new technologies, knowledge must go beyond that of a mere user. We must understand how these systems work, how they treat information and how they process it. It is not uncommon for these systems to also lead to errors, so it is the job of the main surgeon to supervise the correct functioning of the technology throughout the intervention. For this reason, we cannot and should not yet abandon basic training for new surgical residents. They must know “the old way” of operating, but above all surgical anatomy in depth.
The team must also be not only trained in the use of technology but also feel comfortable using it. Let us bear in mind that, at first, the incorporation of these systems involves very important changes in the workflow and frequently increases in surgical times, which are drastically reduced with experience.
The operating room team is like a small orchestra and it is important that each one not only knows how to play their part of the score in the best way, but also how to enter and exit (act or not act) when necessary or not.
And obviously, all this technology cannot work alone. It requires a conductor or a main surgeon who knows how to use it, but above all, who is aware that the most important thing is a very meticulous and documented preoperative planning, an excellent surgical execution and technique and exquisite and humane postoperative care.
You may also like:
