Dr. Robert Louis, a neurosurgeon at Hoag Memorial Hospital Presbyterian in Orange County, CA, is pitched some type of new technology, gadget or medication every day. He’s shown things so often that he developed an internal filter that automatically sets expectations a lot lower than the enthusiasm of the rep. But that all changed in October 2015.
That’s when Surgical Theater reps dropped by to showcase the Surgical Navigation Advanced Platform, or SNAP. Designed by former Israeli fighter pilots, the technology uses virtual reality to allow neurosurgeons to “fly” through a patient’s brain to get a better look at tumors, nerves, blood vessels and tissue prior to surgery. Before surgery, the patient’s brain is captured and recreated as a 3D model for Dr. Louis or his colleague Dr. Christopher Duma, neurosurgeon and director of Hoag’s Brain Tumor Program, to navigate.
Hoag is currently using an Oculus DK2, but the FDA recently cleared the consumer Oculus Rift for use and that will be deployed moving forward in all medical facilities, according to Jim Breidenstein, president and COO at Surgical Theater’s SNAP division.
Louis said prior to the introduction of this technology, he’d have to reference black-and-white 2D “slices” of the brain and then use his imagination (and 20 years of surgical experience) to map out the surgical procedure in his head before entering the Operating Room.
Since SNAP is registered with both Stealth, a technology Hoag uses, and Brainlab, that 3D model of the patient’s brain is used to track the tips of the instruments as the neurosurgeon navigates the brain. It works like a GPS inside the head, allowing doctors to track their instrument in real-time.
“Instead of looking at a 2D model, I can now see the tips of the instruments on the 3D Surgical Theater System on screen and compare that to what I’m seeing through the lens of the microscope,” said Louis, who is also director of Hoag’s Skull Base and Pituitary Tumor Program.
Hoag, one of 10 hospitals using this technology, has already used SNAP on 100 patients.
“We’ve seen an increase in the rate of complete tumor removal and a decrease in the rate of neurological complications,” Louis said.
Louis said this new technology helped him save Marcus Barnes, 41, who had a brain tumor. Louis focuses on non-evasive surgeries whenever possible, preferring to take tumors out through the nose, ear or eyebrow whenever possible. His original plan was to make a small incision by the eyebrow for Barnes, but when he put on the Oculus headset and explored the virtual reality model of his brain, he found that the patient’s optic nerve would block him from extricating the entire tumor that route.
“We changed the approach and we did a small incision behind the hairline instead,” Louis said. “We made this change before even touching the patient and we were able to get the entire tumor out successfully.”
SNAP also played another role in this particular operation. The technology has been designed so anyone, including patients, can get a look inside their head. Louis wheeled the headset into Barnes’ room while he was being prepped for surgery so he could show him why he was changing the operation the morning of, which Louis admits is something that would normally make a patient nervous. But this technology allowed the patient to see exactly what the doctor sees – and will see during surgery.
“Everybody loves seeing their brain in 3D and in color,” Louis said. “They feel much more engaged in their own process with VR. It goes from ‘I trust you’ to ‘I understand what’s going on with my body.’ Research shows patients who are more engaged and have a better understanding of their pathology will have a better outcome.”
In September, Louis will begin testing a brand new augmented reality technology from Surgical Theater. The new technology will be used inside the OR, and use the 3D model of the patient’s head to project a real-time 20-30% shadowed view of exactly where the tumor is via AR while the neurosurgeon is performing the operation through the lens of a microscope or viewing the screen of the endoscope.
“The tumor is visible partially in my field-of-view so I know exactly what direction I’m going,” Louis said. “I don’t think AR will replace the pre-op rehearsal in VR, but it adds to the tools we use during surgery and it’s another big advance to be more precise.”
Louis said the less disruption of normal tissue and critical anatomy in getting to the tumor, the fewer neurological complications and less blood loss there is for the patient.
There are 10 hospitals using this VR technology today, including University Hospitals Case Medical Center, University Hospitals Rainbow Babies and Children’s Hospital, The Ronald Reagan UCLA Medical Center, The Mount Sinai Hospital, Mayo Clinic and NYU Langone Medical Center. Some of these hospitals are using SNAP in an additional way.
VR can also be used to train residents, Breidenstein said.
“Students can see in 20 minutes what has taken neurosurgeons like Dr. Louis 20 years to perfect in his own mind,” Breidenstein said. “It can dramatically shorten the learning curve of tomorrow’s surgeons.”
At UCLA, Dr. Neil Martin uses Surgical Theater to travel pre-operatively through a patent’s head.
There are multi-user options, so the doctor and the student each can have an individual avatar and they can look at the anatomy of the brain from a teaching perspective. This option is also available online, so that the doctor and student don’t have to be in the same state or country.
Breidenstein said over 2,000 patients have been treated using Surgical Theater technology to date.
“By design, we’ve had a limited launch and strategic plan with 10 centers for the current physical year,” Breidenstein said. “In 2017, we’ll take our technology and expand and scale it based on the learning and volumes of clinical data we’re collecting. Our goal it to get SNAP into all key centers in the surgical world.”
Alon Geri, co-founder and executive vice president of engineering at Surgical Theater, said SNAP has been designed to evolve with technology. The Windows-based technology already works on both Oculus Rift and HTC Vive, as well as several enterprise AR devices. Geri said any headset that will be available in the market will be supported in the future, when it makes sense.
Geri, who used to fly Blackhawks in the Israeli Air Force, ended up designing this virtual reality technology on a challenge. He had spent several years developing a virtual reality flight simulator for pilots when a neurosurgeon asked him if he could do the same thing for doctors. He accepted the challenge.
“Once surgeons started to experience it, it blew their minds,” Geri said. “It allows them to prepare for complicated surgery cases and gets them into the zone to go under the microscope.”
This book is an up-to-date reference on all aspects of anticoagulation and hemostasis in neurosurgery. After an opening section on basic principles and drug classes in current use, detailed consideration is given to coagulation issues relevant to all patients, not just neurosurgical ones. The coverage includes, for example, deep vein thrombosis, pulmonary embolism, and disseminated intravascular coagulation. A variety of important issues specific to neurosurgical practice are then addressed, and a summary of current guidelines and best practices is provided. By bringing together the latest knowledge from across the discipline, this book will serve as a sound basis for informed decision making in surgical practice. It will be of daily value for neurosurgeons and trainees worldwide and will also be of interest to emergency room physicians, surgeons in general, critical care physicians, neurologists, and hospital medicine specialists.
Published on: 2016-05-16
Original language: English
From the Back Cover
As the population ages and prophylactic anticoagulation for different cardiac disorders is validated by cooperative trials, it is becoming ever more important that practicing neurosurgeons have the requisite knowledge to manage optimally the opposing processes of anticoagulation and hemostasis. Nevertheless, only a modest amount of structured information is at present available on the subject, with the consequence that decision making is too often insufficiently informed. This book, written by recognized experts, is designed to rectify this situation by bringing together the latest knowledge from across the entire discipline. It will be of daily value for neurosurgeons and trainees worldwide and will also be of interest to emergency room physicians, surgeons in general, critical care physicians, neurologists, and hospital medicine specialists.
About the Author Christopher M. Loftus, MD, Dr.h.c., FACS, is Professor and Chairman, Department of Neurosurgery, and Professor of Neurology at Loyola University Stritch School of Medicine, Maywood, IL, USA. His previous appointments include Professor and Chairman, Department of Neurosurgery, Temple University School of Medicine, Philadelphia, PA; The Harry Wilkins Professor and Chairman and The Esther and Ted Greenberg Professor and Chairman, Department of Neurosurgery, The University of Oklahoma Health Sciences Center, Oklahoma City, OK; and Professor of Surgery (Neurosurgery), The University of Iowa College of Medicine, Iowa City, IA. Dr. Loftus is a Diplomate of the National Board of Medical Examiners and the American Board of Neurological Surgery. He has held many offices in leading professional bodies, including Vice Presidency of the American Association of Neurological Surgeons, and he is currently Treasurer of the World Federation of Neurosurgical Societies. His research interests include intracranial collateral circulation, extracranial carotid occlusive disease, and responses of cerebral blood flow to cerebral revascularization. He is participating in the IHAST cooperative trial for hypothermia in aneurysm surgery and the ISUIA – unruptured aneurysm trial. Dr. Loftus has been a member of the editorial boards of many prestigious journals and is the author of more than 200 articles and book chapters in peer-reviewed publications. He has edited or authored over twenty previous books, including, most recently, Intraoperative Neuromonitoring (McGraw-Hill, New York, 2013; co-editors Biller J and Baron EF).
The olfactory nerve (Latin: Nervus olfactorius), known as the first cranial nerve, or simply CN I, carries the sensory information for the sense of smell. Derived from the embryonic nasal placode, the olfactory nerve is capable of regeneration. The olfactory nerve is sensory in nature and originates on the olfactory mucosa in the anterosuperior nasal cavity.
From the olfactory mucosa, the nerve travels down the olfactory tract until it reaches the olfactory bulb, where the fascicles of the olfactory nerve pass through foramina on the cribriform plate, which resides on the roof of the nasal cavity. These fascicles are not visible on a cadaver brain because they are severed upon removal.
In the sphenoid bone, behind the chiasmatic groove is an elevation, the tuberculum sellae (or the tubercle of sella turcica). A variable slight to prominent median elevation forming the posterior boundary of the prechiasmatic sulcus and the anterior boundary of the hypophysial fossa.
A challenging area in skull base surgery is microsurgery of the tuberculum sellae and sphene-orbital lesions.
This thoroughly revised and expanded atlas is the ideal reference for residents, fellows, and clinicians to review surgical procedures before entering the OR. The authors provide step-by-step descriptions of techniques, clearly delineating indications and contraindications, goals, operative preparation and anesthesia, and postoperative management. The main focus of this book is on teaching neurosurgical techniques at the most detailed level.
Features of the second edition:
A new chapter on proton therapy
An expanded section covering the latest radiosurgery techniques
Nearly 3,000 high-quality images aid rapid comprehension of surgical procedures
Online access to more than 100 surgical technique videos
This book should be read cover to cover by young practitioners several times during their residency and it will keep more experienced neurosurgeons up-to-date on the latest surgical techniques in the field.
Most reports have characterized postoperative epidural hematoma as occurring early after operation and accompanied with neurological deficits. But it can happen even two weeks after spinal surgery with no pain. Surgeons thus may need to follow up patients for at least a few weeks because some complications, such as epidural hematomas, could take that long to manifest themselves 2).
Awad et al. 3) divided potential risk factors into two categories, preoperative and intraoperative factors. Significant preoperative risk factors included nonsteroidal antiinflammatory drug use and patient age more than 60 years; significant intraoperative risk factors included multiple-level operation, anemia, and large blood loss. Sokolowski et al. 4) reported that age greater than 60 years, multilevel procedures, and preoperative international normalized ratio (INR) correlated with postoperative hematoma volumes.
Parthibian and Majeed described a case which developed following an episode of violent twisting movement 5).
Sokolowski et al. reported four cases of delayed symptomatic epidural hematoma without coagulopathy. In these cases, though, the initial symptoms included severe pain and muscle weakness at the level of previous surgery, the same symptom pattern that accompanies hematomas occurring shortly after surgery 6).
Only one rare case of delayed onset of epidural hematoma after lumbar spine surgery whose only presenting symptom was vesicorectal disturbance is reported by Kamoda et al. 7).
Surgical evacuation if symptomatic.
The administration of prothrombin complex concentrate (PCC) facilitates emergency spinal surgery in anticoagulated patients who present with acute spinal pathology requiring urgent neurosurgical decompression. The risk of PCC-associated thromboembolic events seems to be low and justifies the use of PCC in order to avoid permanent disablement resulting from delayed surgery or non-operation 8).
Sokolowski et al. reported four cases of delayed symptomatic epidural hematoma without coagulopathy. In these cases, though, the initial symptoms included severe pain and muscle weakness at the level of previous surgery, the same symptom pattern that accompanies hematomas occurring shortly after surgery 9).
Uribe et al. report a series of delayed epidural hematomas in a subset of patients who awoke from surgery neurologically unchanged and then deteriorated more than 3 days after their index procedure.
They reviewed the database of six spine surgeons over a 4-year period, looking for presence of epidural hematomas as a cause of clinical deterioration after an asymptomatic postoperative period of at least 3 days, and identified a subset of patients who awoke from surgery neurologically unchanged and then deteriorated more than 3 days after spinal surgery.
Of 4,018 patients, they identified seven with spinal epidural hematoma who presented more than 3 days after their index procedure. The initial presenting symptom, which heralded the subsequent onset of neurological deterioration, consisted of severe sharp pain with radiation to the extremities. The average time to neurological deterioration was 5.3 days. Fifty-seven percent of the patients had multiple previous spinal surgeries at the site of the epidural hematoma. Surgical evacuation of the epidural hematomas resulted in neurological improvement in five patients. Persistent neurological deficits were observed in two patients.
Delayed spinal epidural hematomas are an uncommon cause of delayed deterioration after spinal surgery. Previous surgery with attendant scarring that results in impairment of clot resorption may be a contributing factor in the development of the condition 10).
A 64-year-old woman underwent an uneventful total knee arthroplasty operation under a spinal anesthetic. A lumbar puncture was performed in the L2-L3 interspace, that was atraumatic and successful on the first attempt. The operation was uneventful. On the third postoperative day, the patient developed a SEH that expanded from C2 to T3 levels. She was presented with bilateral shoulder pain, muscle weakness of the upper extremities with normal sensation, followed by paraparesis. The magnetic resonance imaging (MRI) revealed a large vascular malformation, partially ruptured forming a hematoma compressing the spinal cord toward the vertebral bodies The patient was treated conservatively and full recovery was achieved 11).
An 86-year-old woman was scheduled to undergo aortic valve replacement and coronary artery bypass graft. On postoperative day 3, she developed sudden-onset neck pain followed by weakness in the right arm. Her symptoms worsened with time, and she developed paraplegia. At 60 h after the first complaint, spontaneous spinal epidural hematoma (SSEH) from C2 to C6 with spinal cord compression was diagnosed from a magnetic resonance image of the cervical region. We decided on conservative therapy because operative recovery was impossible. Delayed diagnosis led to grievous results in the present case. When neurological abnormalities follow neck or back pain after open heart surgery, SSEH must be considered in the differential diagnosis. Further, if it is suspected, early cervical computed tomography/magnetic resonance imaging and surgery should be considered 12).
A rare case of delayed onset of epidural hematoma after lumbar surgery whose only presenting symptom was vesicorectal disturbance. A 68-year-old man with degenerative spinal stenosis underwent lumbar decompression and instrumented posterolateral spine fusion. The day after his discharge following an unremarkable postoperative course, he presented to the emergency room complaining of difficulty in urination. An MRI revealed an epidural fluid collection causing compression of the thecal sac. The fluid was evacuated, revealing a postoperative hematoma. After removal of the hematoma, his symptoms disappeared immediately, and his urinary function completely recovered 13).
Unilateral sensorimotor deficit caused by delayed lumbar epidural hematoma in a parturient after cesarean section under epidural anesthesia 14).
A patient 9 days after he underwent laminoplasty. The authors draw attention to the possibility of delayed PSEH and its triggering mechanism. In this case, a 59-year-old man with no history of bleeding disorder underwent cervical laminoplasty for mild myelopathy. On the 7th postoperative day computed tomography demonstrated no abnormal findings in the operative field. On the 9th postoperative day, while straining to defecate, the patient suddenly felt neck and shoulder pain, and tetraplegia rapidly developed. Magnetic resonance imaging demonstrated a huge epidural hematoma. The clot was evacuated during emergency revision surgery, during which the arterial bleeding from a split muscle wall was confirmed. The postoperative course after the revision surgery was uneventful and the patient had none of the previous symptoms 1 year later. A PSEH causing paralysis can occur even more than a week after surgery. The possibility of a delayed-onset PSEH should be kept in mind, and prompt diagnosis should be made when a patient presents with paresis or paralysis after an operation. The authors recommend advising patients that for a while after surgery they avoid strenuous activity 15)
Treatment of thromboembolic disease in the postoperative lumbar spine patient is controversial. This case report describes an epidural hematoma with neurologic sequelae in an elderly patient who received intravenous heparin therapy over 2 weeks after lumbar decompression 16)
1) , 10) Uribe J, Moza K, Jimenez O, Green B, Levi AD. Delayed postoperative spinal epidural hematomas. Spine J. 2003 Mar-Apr;3(2):125-9. PubMed PMID: 14589226.
2) , 7) , 13) Kamoda H, Ishikawa T, Miyagi M, Eguchi Y, Orita S, Suzuki M, Sakuma Y, Oikawa Y, Yamauchi K, Inoue G, Takahashi K, Ohtori S. Delayed postoperative epidural hematoma presenting only with vesicorectal disturbance. Case Rep Orthop. 2013;2013:861961. doi: 10.1155/2013/861961. Epub 2013 Sep 1. PubMed PMID: 24073350; PubMed Central PMCID: PMC3773434.
3) Awad JN, Kebaish KM, Donigan J, Cohen DB, Kostuik JP. Analysis of the risk factors for the development of post-operative spinal epidural haematoma. Journal of Bone and Joint Surgery B. 2005;87(9):1248–1252.
4) Sokolowski MJ, Garvey TA, Perl J, et al. Prospective study of postoperative lumbar epidural hematoma: incidence and risk factors. Spine. 2008;33(1):108–113.
5) Parthiban CJ, Majeed SA. Delayed spinal extradural hematoma following thoracic spine surgery and resulting in paraplegia: a case report. Journal of Medical Case Reports. 2008;2, article 141
6) , 9) Sokolowski MJ, Dolan M, Aminian A, Haak MH, Schafer MF. Delayed epidural hematoma after spinal surgery: a report of 4 cases. Journal of Spinal Disorders and Techniques. 2006;19(8):603–606.
8) Beynon C, Potzy A, Unterberg AW, Sakowitz OW. Prothrombin complex concentrate facilitates emergency spinal surgery in anticoagulated patients. Acta Neurochir (Wien). 2014 Apr;156(4):741-7. doi: 10.1007/s00701-014-2032-x. Epub 2014 Feb 26. PubMed PMID: 24570188.
11) Makris A, Gkliatis E, Diakomi M, Karmaniolou I, Mela A. Delayed spinal epidural hematoma following spinal anesthesia, far from needle puncture site. Spinal Cord. 2014 Jun;52 Suppl 1:S14-6. doi: 10.1038/sc.2013.174. Epub 2014 Jan 21. PubMed PMID: 24445973.
12) Kin H, Mukaida M, Koizumi J, Kamada T, Mitsunaga Y, Iwase T, Ikai A, Okabayashi H. Spontaneous spinal epidural hematoma presenting as paraplegia after cardiac surgery. Gen Thorac Cardiovasc Surg. 2014 Apr 11. [Epub ahead of print] PubMed PMID: 24722959.
14) Yao W, Wang X, Xu H, Luo A, Zhang C. Unilateral sensorimotor deficit caused by delayed lumbar epidural hematoma in a parturient after cesarean section under epidural anesthesia. J Anesth. 2012 Dec;26(6):949-50. doi: 10.1007/s00540-012-1444-0. Epub 2012 Jul 13. PubMed PMID: 22790515.
15) Neo M, Sakamoto T, Fujibayashi S, Nakamura T. Delayed postoperative spinal epidural hematoma causing tetraplegia. Case report. J Neurosurg Spine. 2006 Sep;5(3):251-3. PubMed PMID: 16961087.
16) Spanier DE, Stambough JL. Delayed postoperative epidural hematoma formation after heparinization in lumbar spinal surgery. J Spinal Disord. 2000 Feb;13(1):46-9. PubMed PMID: 10710150.