Medical Device Daily
Every time neurosurgeon Kamal Thapar, MD, operates on a patient to remove a brain tumor, he knows there's a family waiting for him to come out and give a status report. Their first questions: "Is my loved one OK and were you able to remove all of the tumor?"
"I used to have to give a real milquetoast response. 'I think so,' I'd tell them," Thapar told Medical Device Daily. "Then, the next day I'd do an MRI scan on the patient, but I still couldn't be sure that I got it all."
That's no longer the case. Thapar is director of the Brain & Spine Institute at Sacred Heart Hospital (Eau Claire, Wisconsin), a community hospital that has installed a specialized neurosurgical suite – dubbed SmartOR – that includes a confluence of technologies which enable surgeons to provide the same state-of-the-art treatment for neurosurgery, spine and trauma patients found at advanced academic centers.
"If you're taking out a lung tumor, you can make a large incision, put your fingers in there and maul around to make sure you get it all, but you can't do that in the brain," Thapar said. Brain tissue is extremely delicate. One wrong move and that patient might survive, but he also might spend the rest of his life in a nursing home, coping with neurological damage.
"There is no tolerance for injury to the brain," he said. "If we take a look at neurosurgery, there are two problems: How to get a tumor out and how not to destroy the patient. The goal is to treat the tumor in the most minimally invasive corridor of access. And if there's any place in the human body where minimally invasive means something, it's the brain."
Sacred Heart is one of a handful of community hospitals investing in the kind of technology needed to perform neurosurgery and spinal surgery with the most advanced tools available. Specifically, it is one of six hospitals in the U.S. – and of only 17 hospitals in the world - to offer the grouping of technology.
The enabling technology provides real-time, high-definition data, allowing surgeons to chart an exact path to tumors during operations so that surrounding healthy tissue is not damaged. Here's a short list of what's included in the SmartOR:
• The most important tool is an intra-operative IMRIS MRI (iMRI), which allows the surgical team to verify whether a cancerous tumor has been completely removed, greatly reducing the need for follow-up surgery. The iMRI comes to the patient, reducing the risk of complication. Moreover, the OR is set up so that standard surgical devices don't have to be removed from the room.
The iMRI was developed by Siemens Medical Solutions (Malvern, Pennsylvania) and Imris (Winnipeg, Manitoba). The companies signed a global OEM agreement several years ago in which Siemens Magnetom Espree and Magnetom Symphony MRI systems were incorporated into Imris' ceiling-mounted surgical imaging systems, specifically for use in neurosurgical, spinal and soft tissue procedures (MDD, April 6, 2006)
• Monitoring and documenting every aspect of the procedure with high-definition 3-D pictures, the VectorVision Sky, from BrainLAB (Feldkirchen, Germany/ Westchester, Illinois), acts like a global position system for the brain, helping Thapar and team target the masses with greater accuracy.
• One of Thapar's most coveted tools is a high-magnification Zeiss OPMI Petro C Microscope, made by Carl Zeiss Meditec (Jena, Germany/Dublin, California). It enables the neurosurgeon to clearly see as they navigate through sensitive areas of the brain while operating. The patient's brain map, targeting the diseased tissue, is superimposed on the microscope screen so that the surgeon never has to look up.
• Bringing it all together with real-time information, a surgical mapping system from BrainLAB called BrainSUITE, which stores, references and displays images within seconds on flat screens mounted in the operating room, giving the entire surgical team a picture of the operation as it progresses, allowing for easier consults.
"This technology allows us to address things not addressable in the past, such as lesions or abnormalities that we couldn't previously see," Thapar said. "They are mapped out carefully and you can get where you need to go [inside the brain] more safely. We're safely working on areas of the brain that were previously considered inaccessible."
Residual tumor is a common problem often faced by patients and their neurosurgeons. Previously, these patients had to wait for a follow-up MRI to get a clear picture. Then follow-up surgery and more danger of injury to the brain.
"SmartOR allows us to verify that we've removed the tumor completely while the patient is still on the table," he said.
The concept of iMRI is not new, but when the first-generation iMRI machines first came out, they were cumbersome, plus you couldn't use the standard equipment found in neurosurgery, specifically metal and stainless steel tools without the possibility of them being grabbed by the giant magnets of MRI.
The technology has now been morphed to work in an OR.
"At the right time the doors open and a magnet migrates over the patient, but we can still use all the same tools. We're bringing the mountain to Mohammed," Thapar said.
At the same time, BrainSUITE - an off-the-shelf software package tweaked for Sacred Heart - brings those pictures into the eye field of the microscope with an image that's superimposed on the patient's brain.
The $6 million SmartOR setup got full approval at the end of November 2008 and 12 patients have since been treated.
"All of those patients' surgeries went magnificently," Thapar said. "We had several cases where we thought we had completely removed the tumor and then, while they were still on the table, we found small nodules hiding behind blood vessels or in inaccessible places. There's no question it increased the accuracy of surgery. It's given us more confidence to be more aggressive in our treatments while preserving neurological function."
He said that in addition to using the equipment for delicate surgery, the OR will double as a secondary diagnostic location, further validating the $6 million expense.
Thapar also pointed out that the SmartOR is about more than a bunch of new technology in the OR.
"It's an evolution. It makes sense for the hospital because it generates revenue from a diagnostic standpoint and makes surgery safer for patients," he said.
It also has raised the bar for everybody on staff. "This is a learning curve for our staff – we're still learning what things mean on iMRI. Everyone is involved. Even the housecleaner needs to know about magnetism. Everybody's much sharper," Thapar said.
He said the hospital has been doing intra-operative computed tomography (iCT) since 2003 for spinal surgery patients. Typically when implants and screws are placed, there's a 5% chance that they could be malpositioned, resulting in an average of 3% of these patients going back for surgery to fix the malpositioned implants.
"When we introduced iCT scanning during spinal surgery, we reduced the reoperation rate to zero," he said.