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• A New Microscope Facilitates Microneurosurgery

By Alfredo Arango
Medical Editor

A new surgical microscope, particularly useful in microneurosurgery, has begun to be used in some hospitals in the United States. An example of its application was a recent replacement of vertebrae with titanium prostheses in a 56-year-old patient, who was virtually immobilized due to pain.

“In this case we are going to remove the 10th and 11th vertebrae affected by osteomyelitis produced by a disc infection, which has extended to the vertebral bodies, thereby destroying them and causing an abscess behind the vertebrae that is similar to a wedge compressing the spinal cord. The area is approached through the chest, because it is not possible to enter through the back without displacing the spinal column. The spinal cord cannot even be displaced a millimeter, because the patient would become paralyzed. At this point, the use of a highly sophisticated microscope is key to a successful intervention,” explains Dr. Pablo Acebal —a neurosurgeon affiliated with Kendall Regional Medical Center— who is in the operating room seconds before starting the surgical procedure.

The microscope is not used throughout, but rather at the most critical moment of the operation. In the case of vertebrae replacement, a complex reconstructive procedure that can last seven to nine hours, first a cardiothoracic surgeon performs a thoracotomy, meaning that a long incision is made on the patient’s side, which includes cutting ribs, deflating a lung and displacing organs to make space and expose the spine. Afterwards, the neurosurgeon begins to cut the damaged vertebrae and remove the fragments, until the area is completely free of debris. This is where the microscope comes into play. Lastly, a prostheses or titanium cylinder is inserted replacing the removed vertebrae, and it is fixed in place by screwing a bar onto the healthy adjacent vertebrae in order to stabilize the area. This is called fusion.

Dr. Acebal explains that the main advantages offered by the new surgical microscopes are their brighter and more precise lighting of the surgical area, not only for the main surgeon but also for the assisting physician; as well as integration of MRI and CT systems.

“At the same time I am operating, I can view real images of the patient’s studies, without having to look outside the surgical field. This integration of navigating system with the microscope is revolutionary in neurosurgery, because the images guide the surgeon during the operation,” adds the specialist.

“This translates into improved safety for the patient, because it allows the surgeon to know exactly where he is, and to have better control to preserve vital areas of the brain or the spinal cord,” the surgeon says.

Zeiss, the company that manufactures this new Pentero microscope, sums up the benefits offered by this innovative technology by saying that it allows intra-operative diagnostics, integration of the entire digital video chain, integration of the surgical microscope into the hospital’s information and communication infrastructure, and user-friendly solutions for the OR staff.

Carlos Avalos, who represents Medtronics in the OR, and specifically in the vertebrae replacement case, has provided the titanium prostheses, as well as certain instruments and other products needed in this procedure, explains that the microscope is a great advance for these delicate operations that are still necessary. “At present, this high-tech microscope is essential to giving the best use possible to the prostheses and instruments we provide, which are also state-of-the-art technology,” says Avalos. “In the future, we are going to use more biological materials, similar to bone, which the body will be able to incorporate much more easily. Biological products, which one would even be able to eat or have injected, will probably make such invasive procedures unnecessary, because they will be able to regenerate the body’s tissues. Moreover, instead of fusions, such as the ones we now perform, it would be possible to preserve movement, which is quite dynamic in the case of the spine, as it can flex, stretch and rotate. We are approaching that point. The future is quite unbelievable,” he adds.

A week after this reconstructive surgery of the spine, the patient on whom the procedure was performed is recovering satisfactorily. “With the aid of such innovative technology, the patient has recovered the ability to move his legs. He is taking antibiotics, and will continue to do so for a long time. We trust his rehabilitation will be complete, and we also hope he will eventually be able to walk again,” Dr. Acebal adds.

FIRST MICROSURGERIES
The first microsurgeries were performed for blood-vessel repair. The first one to describe such a procedure was Jules Jacobson, a vascular surgeon, in 1960. Using an otolaryngology microscope he managed to reconnect 1.4 mm vessels and he coined the term “microsurgery.” Kleinert y Kasdan, hand surgeons, performed the first revascularization on a partial finger amputation in 1963. Today, the microscope is used in various surgical fields, thus contributing to the speedy progress of medicine.