By Dr. Ravindra Patil
With the advancement in complex surgeries, the human eyes and hands are no longer enough! Complex biomedical equipment helps surgeons conduct operations which would not have been possible otherwise.
You may have heard of stitches being taken with thread thinner than the human hair. To be able to knot a stitch with thread so thin requires skill and surgical loupes [spectacle like devices which magnify the view many times]. Operating Microscopes help surgeons operate on organs or tumours as small as 1 – 2 mm. Endoscopes help surgeons reach small but extremely vital organs like the pituitary gland through the nose!
But that is not enough. Now complex brain and spine surgeries require precise incisions on the skin and drills on the bones to reach the tumour or diseased portion accurately and remove it.
Imagine a 3 mm non-cancerous brain [or spine] tumour is pressing a small part of the brain which controls speech. So, the patient’s speech gradually deteriorates. As the tumour is non-cancerous there is no fear of its spreading to distant parts. But even non-cancerous tumours will keep on growing and putting further pressure on the brain [or spinal cord] and the patient will suffer more and more loss of function.
The obvious solution is to remove the tumour. But it is not so simple. In brain and spine surgeries, the surgeons can approach the area to be operated on only after cutting through bones and very tough ligaments. And remember, the opening must be as small as possible. Larger the incision or cut in the skull or vertebrae, the higher the chance of damaging surrounding healthy parts and the incidence of surgical site infection.
So minimal cutting is not only better but essential!
The bones which protect the delicate nerves and brain or spinal cord tissue within are tough. Cutting such bones requires tough wear-resistant drills and saws. These drills or saws rotate at hundreds or thousands of revolutions per minute.
Imagine how much devastation such saws or drills will cause on delicate soft tissue if these instruments come in contact with brain tissue or spine tissue.
Hence, accuracy in surgery of brain and spine is of the greatest priority.
Here is where surgical navigation systems come in.
The greatest boon of recent times is driving a car with Google or other navigation systems. They even tell us about a traffic jams, so that we can avoid those roads.
Google maps rely on satellites and geographical location markers to identify your position and then guide you to your destination.
People also do criticise using google navigation in cars saying that they know the roads so well that they do not need such fancy gadgets. These people are right. But whatever they say, google maps are very, very useful for driving over unexplored routes. Also, in pitch darkness at night, the navigator shows oncoming turns and crossroads which could have been seen during daylight hours and can be unexpected in the night.
All the advantages and disadvantages apply to using the navigation in brain and spine surgery.
Navigation assisted surgical techniques also have navigation markers similar to Google. While Google markers are located in geographic locations, surgical navigation markers are attached just prior to surgery to spots on the skin through which the brain and spine surgeons can incise the skin, drill through or cut open bones, and insert small instruments or drills or screws or K Wires or such to pierce the bone at the precise points and with minimal injury to surrounding healthy tissue.
Skilled and experienced brain and spine surgeons were critical of surgical navigation in the beginning. But when they all realised the millimetre sharp accuracy achievable with Surgical Navigation, the general consensus opinion is more and more in favour of using navigation for brain surgeries.
The patient undergoes a CT scan which is a part of the diagnostic and surgical system. Markers are attached at the location of the tumour. The surgical instruments are also marked and visible in the highly advanced image intensifying television system so that the surgeon can see the location of his knife, drill or screw in relation to the tumour [marked by the special markers] in three dimensions. Thus equipped, the surgeon can then make an incision and put in a drill, screw, nail or a wire to fix a vertebra or a bone.
Besides, three-dimensional views of the operating field can be seen as per the neurosurgeon’s requirements, on the flat screen viewer of the surgical navigation system.
Getting such clear views is a revolution because, in open surgery, the view that a surgeon gets is very limited and restricted because of small incisions.
Try to draw a square or a circle on paper. So easy! Now try to draw the same on the reverse side of the paper without looking at it. Slightly difficult, but possible.
Now take a glass and try to write inside it on the bottom without looking. You will need a long pen and you may be able to scratch but not write accurately.
Spine and brain surgery is far more complex and in three dimensions. There is no straightforward approach to the part to be operated. In such situations, surgical navigation systems are not just ‘GOOD TO HAVE’, they are ‘MUST HAVE’.
What applies to the brain also applies to the Spinal Cord. The brain has hard covers over it called the skull and dura mater. The spinal cord is covered and protected by the vertebrae and the extension of the dura mater. Compared to the skull and the brain, the spinal cord is perhaps equally difficult to approach safely and operate.
Navigation assisted spine surgery is a group of technologies, which allow the surgeon to access real-time, three-dimensional and virtual images of the spine in relation to the surgical instruments during the operation. Again, accuracy in approaching the ‘pressure point’ of nerves or the spinal cord leads to predictable and safer surgical outcomes.
‘Pressure point’ in spine related pain means the pain because of pinched nerves. This happens because ‘slipped discs’ or change in the structure of the vertebral column presses nerves when they emerge from the spinal cord and pass through small holes in the vertebral columns through which nerves come out.
All in all, the fundamental idea in computer navigation assisted spine and brain surgery is to reach the diseased portion very precisely and remove the tumour or correct the pressure or constriction very accurately. As has been mentioned, tumours which are only a few mm wide can be thus excised.
These same tumours would be a big problem if excised without navigation. The neurosurgeon would in all likelihood have removed healthy brain tissue surrounding the small tumours and that would have led to functional damage after surgery. Those functions which were perfectly normal before surgery might get affected because of inaccurate surgery. Thus although the patient’s tumour would be removed, a small part of his healthy brain tissue would also go! That is the price which has to be paid if neurosurgery is not done with extreme accuracy.
Samarth Neuro Hospital of Sangli-Miraj is the first hospital in the area to have a navigation system for brain and spine surgeries. With their in house CT scan and cath lab, almost all complex brain and spine surgeries can be done safely in Samarth Neuro Hospital.
There used to be a lot of concern about safety in brain and spine surgeries. But now with such accurate diagnostic marking systems, you don’t have to go to Pune and Mumbai in case you need brain or spine surgery, Samarth Neuro Hospital in Sangli-Miraj has it all!
Samarth Neuro and Superspeciality Hospital has 100+ beds & specializes in emergency surgery for neurological issues/disorders & diagnostics.
Samarth Neuro and Superspeciality Hospital
