New Visualization Technology Advances Neurosurgery

LEXINGTON CLINIC NEUROSURGEONS USE AIRO® MOBILE INTRAOPERATIVE CT AT SAINT JOSEPH HOSPITAL, AMONG OTHER TECHNOLOGY, TO BALANCE PATIENT NEEDS AND EXPECTATIONS FOR OPTIMAL TREATMENT

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LEXINGTON It may sound unusual to hear a surgeon predict that the future of their specialty will be not to operate, but that is exactly the prediction of the neurosurgeons at Lexington Clinic.

“The long-term future of neurosurgery, I hope, is not surgical,” says Matthew P. Tutt, MD, with Lexington Clinic Neurosurgery. “I really hope that someday we’re not doing surgery on brain tumors. It’s going to be more targeted, immune-modulated treatments.”

Lexington Clinic Neurosurgeon Robert D. Owen, MD, agrees: “I think we will be able to diagnose what type of brain tumor it is based upon a scan … There are going to be fewer cranial surgeries for brain aneurysms. Even today the vast majority are being treated endovascularly … There will be more indications for functional neurosurgery – placing brain stimulators to treat movement disorders and different psychiatric orders, which is already happening now.”

As brain surgery continues to evolve, Owen expects that neurosurgeons will adapt to fill those roles. However, spinal surgery is not something the physicians see going away. “What we do in the spine, where there is pressure on a nerve and the only way to make it better is to take pressure off, that can’t be done with medicine. I don’t see that changing. The advances in spine surgery will be – what can you do with less?” says Gabriel H. Phillips, MD, of Lexington Clinic Neurosurgery.

For now, there are plenty of surgical and non-surgical treatments and technologies the neurosurgeons employ that are defying misconceptions and improving outcomes for brain and spine surgery. One such technology is the Airo® Mobile Intraoperative CT scanner, available at Saint Joseph Hospital, part of KentuckyOne Health.

A Comprehensive Brain and Spine Surgery Practice

The surgeons of Lexington Clinic Neurosurgery see adult patients with a wide range of brain and spinal cord problems, with the exception of acute trauma, aneurysms, or vascular problems. They treat primary brain tumors, brain metastases, pituitary tumors, hydrocephalus, and chiari malformations, as well as spinal tumors, lumbar and cervical disc herniations, and degenerative spine problems. The physicians at Lexington Clinic Neurosurgery estimate their practice is 30 percent cranial and 70 percent spinal. Geographically, the practice draws patients from central, eastern, and southeastern Kentucky.

With spinal issues representing the largest portion of their practice, the most common presentations the Lexington Clinic neurosurgeons see are severe neck and arm pain or severe back and leg pain. Sources of the pain are usually herniated discs or degenerative issues, caused by the daily toll of gravitational forces on the body. “One way the body reacts to wear and tear disease is by losing a lot of the cushion in the spine with the disc space, and when you lose that cushion, the body reacts to it by building excessive bone or arthritis. And those can be contributing problems that cause pinching of the nerves,” says Phillips.

Their first approach is non-surgical, including conservative therapies such as physical therapy, steroids, and short-term anti-inflammatories. If those fail, they discuss surgical options, both minimally invasive and open. While their main focus is minimally invasive techniques when they are in the best interest of the patient, Owen says, “There is a role for open surgery when a more aggressive opening and exposure to do an adequate operation is required.”

Improving Surgical Accuracy with Airo CT

When surgery is indicated, one technology that is improving accuracy and decreasing post-op issues for Lexington Clinic neurosurgeons is the Airo Mobile Intraoperative CT at Saint Joseph Hospital. Just like a regular CT, but with a very large opening to accommodate a surgical patient, the Airo CT is “utilized during surgery and immediately allows us to touch points in the spine and look at the CT scan and verify that our position is accurate and we’re placing the screw in its precise location, in the strongest possible position,” says Tutt. It is particularly advantageous when doing fixations in the pelvis or mid-spine, which are difficult to visualize with traditional intraoperative x-ray.

In addition to better visualization for the surgeon, the technology allows for quicker, less invasive procedures and less exposure of the spine, which minimizes pain and post operative issues for patients. “If I’m going to intervene, I want as little damage as possible to the surrounding tissue while still accomplishing the goal of the surgery. Airo is one more weapon in our arsenal where we can do that and do it safer and less invasively than what we’ve done in the past,” says Phillips.

Airo also has the potential to affect and improve long-term patient outcomes. “In select patients, this equipment increases the accuracy of instrumentation placement and that equals fewer potential complications. Well-placed instrumentation means a lower chance of a fixation failing down the road,” says Owen. “Yesterday when I used the equipment, there were two instances where I altered the location of the instrumentation after checking with the navigational system.”

The surgeons say they often use the Airo CT for revision spine surgery because of the complexity of the procedure. In some cases where patients have been told there is nothing more that can be done, the Airo is allowing surgeons to extend the fusion down to the pelvis safely. “The intraoperative CT is the correct tool for that problem. It enables us to place fixation down into the pelvis more safely and faster than we’ve ever been able to do,” says Tutt.

And not only can the surgeons use the Airo CT during surgery for screw placement, they can also repeat the CT at a lower radiation dose before closing and leaving the operating room to ensure everything is correct.

Saint Joseph Hospital was the eighth center in the country to get the Airo CT and is the second busiest center in the country. The Lexington Clinic neurosurgeons estimate they use it three to four times per week.

Managing Expectations and the Successful Practice

Deciding which treatment option to pursue is not always clear. Despite common misconceptions, Tutt says, “not every back pain is a surgical problem.” He divides patients into three categories: those that do not have a surgical option, those that definitely need surgery, and those that fall in between. “So many patients fall in the middle. There are options for helping them but gray areas as to how much it will do for pain. “That’s the art of what we do, talking patients through understanding the risks and benefits of the procedure.”

Whatever the future of neurosurgery holds, the physicians of Lexington Clinic Neurosurgery are united in their collaborative effort to find the best solution for each patient, whether surgical or not.

Tutt, originally from Lexington, joined Lexington Clinic in 2010 after completing medical school at Emory University in Atlanta, Ga., and a residency in neurosurgery at the University of Kentucky (UK). He says he enjoys neurosurgery because it “is a very clean surgery, very precise, and usually involves the newest technology for brain and spinal surgery,” and probably learned his love of medicine from his father, a neurosurgeon, who still works next door, although he has retired from surgery. Tutt’s other loves are spending time with family, the outdoors, and working with horses.

Owen grew up in rural Indiana in a family of firemen. He decided he wanted to attend medical school at Indiana University after his father got him a job in an emergency room as an orderly. After pursuing interests in emergency medicine and internal medicine, Owen spent a month in pediatric neurosurgery, and was hooked. “I remember the first time I saw a craniotomy. I didn’t know this even as a medical student, but the brain pulsates every time you have a heartbeat. That’s something I’ll never forget,” he says. Owen also attended UK for his neurosurgery residency and completed a fellowship in pediatric neurosurgery. He then went on to practice at UK for six years prior to joining Lexington Clinic in 2011.

Phillips is the newest member of the team, joining Lexington Clinic two years ago. A native of Tennessee, he says his grandfather, a family physician, was one of the role models that piqued his interest in medicine. After earning his undergraduate degree at Duke University, Phillips completed a year at the National Institutes of Health doing research in neurogenetics before starting medical school at the University of Tennessee in Memphis, where he also completed a residency with an emphasis on complex spine minimally invasive surgery and cranial surgery.

“We’re a young group and we get along well. A surgeon who is happy with their partners and their practice is a better surgeon I believe,” Owen concludes.

The advances in spine surgery will be – what can you do with less?— Gabriel H. Phillips, MD.

We’re a young group and we get along well. A surgeon who is happy with their partners and their practice is a better surgeon I believe.— Robert D. Owen, MD

The long-term future of neurosurgery, I hope, is not surgical.—Matthew P. Tutt, MD

AIRO ACROSS THE BLUEGRASS

KentuckyOne Health is investing in Airo® Mobile Intraoperative CT technology to the benefit of physicians and patients across the state. Not only is the Airo CT available at Saint Joseph Hospital in Lexington, it is also available at Jewish Hospital in Louisville.

“At Jewish Hospital, we are pleased that KentuckyOne has committed to the Airo technology by also installing a unit at our facility in Louisville. This will allow access to the advantages of this navigational technology for brain and spine care to all Kentuckians that rivals what is available at the most advanced research centers across the country,” says Thomas Becherer, MD, FAANS, FACS, KentuckyOne Health Neurosurgery Associates in Louisville.