Moving Neurosurgery Into the Future

This piece was ghost-written for Edward F. Aulisi, MD, a spine neurosurgeon at MedStar Washington Hospital Center. Sal did the research and interviewed Dr. Aulisi to create the article under his byline.

MedStar Washington Hospital Center made history this summer when it became the first hospital in the United States to perform minimally-invasive spine surgery using Brainlab’s Cirq® robotic arm.

This giant step forward in surgical accuracy and safety came after months of effort and collaboration between our team, hospital leadership,  patients, and the manufacturer. Since then, we have performed more than 50 procedures with the help of Cirq, and it’s already proven itself a game changer.

In fact, this technology has the potential to revolutionize complex neurosurgery. We are privileged to be the first in the country to adopt it.

A New Level of Accuracy

In spinal surgery, accuracy is everything. The spinal column is composed of stacked bones, called vertebrae, that flex and support other components of the skeleton and protect the spinal cord. The spine is around 25 inches long in the average person, but the width of any single vertebra is only an inch or two.

Within the small space of a single vertebra, neurosurgeons must accurately identify and isolate bone, nerve, tendon, muscle, and other structures during surgery. The surgeon must know the exact location of the surgical instruments at any given moment.

Cirq and its 3D CT scanner, Airo®, work in tandem to help locate instruments more accurately than any other I have used to date. Beyond making surgery safer, it’s making it better, with sharpened control that lets our surgical team carefully tailor each procedure to the patient’s
unique anatomy and disease.

How It Works

With cameras, a computer, and the Airo CT scanner, Cirq supports the procedure with rock-solid stability and sub-millimeter accuracy, finer than even the most agile and steady surgeon’s hand. It is a true robotic assistant; as the surgeon performs the procedure, the robot positions and holds tools and surgical instruments with the greatest accuracy.

We have already employed Cirq to assist in spinal fusion, where we use strong rods to connect a weakened, diseased spinal vertebra to healthier neighboring vertebrae that can help share the load. Those rods are mounted to tiny screws that secure them firmly to bone.

In the past, surgeons would use their best judgment, guided by traditional X-ray fluoroscopy. That technology takes longer, requires a significantly higher dose of X-ray, and delivers far less resolution than Airo.

With Cirq and Airo, not only can we isolate bone, we can decide exactly which part of the bone to target, selecting the densest, healthiest tissue. And we can precisely control angle and depth for the strongest, safest mounting point—without affecting the spinal cord or other nearby structures.

The Procedure

Modeled on the human arm, Cirq is a small robotic device that mounts onto the operating table. It’s so light that one person can set it up without assistance. With the Cirq in place, we make small incisions in the patient’s back, temporarily move the muscle aside and mount a small registration device directly to bone.

The robot arm uses its camera to find the points on the registration device and determine exactly where everything is in the space. Then, we use the Airo to scan the area, with images captured at a very low X-ray dose in just 15–20 seconds. In a moment’s time, I have a full three-dimensional view of the spinal column that I can rotate in any orientation to choose the best possible mounting points.

During the surgical process, I watch a monitor, very similar to the heads-up display in a fighter jet, the technology that inspired image guidance. When the screws are in place, we conduct another scan to ensure that the angle, depth, and connection are perfect. This is very important because everyone’s anatomy is unique. We must get the angle and depth just right. It’s like hanging a picture hook on the wall—the better the mounting point, the stronger it is and the more force it can withstand.

Other Applications

The system also excels in trauma cases and revision surgery—when an older surgery develops problems and requires repair. With Cirq, we can install screws in places that were impossible to reach with older technology—so we have many more options. For
example, we can carefully install two screws on either side of an area that isn’t strong enough to support one.

In surgery, knowledge is power

This is a whole new world that will increase the number of people who can be helped by surgery—even in cases considered inoperable in years past. For instance, Cirq will also become valuable in cranial surgery. We have already deployed the Airo scanner 600 times for cranial cases, becoming one of the fastest growing sites in the world. Now, adding Cirq to the mix will enhance speed and accuracy.

Another area where I expect the technology to have particularly dramatic impact is in limb-saving cancer surgery. For example, we sometimes remove diseased bone and replace it with a prosthetic, an artificial implant. This is normally achieved over two surgeries. During the first we locate the disease, remove it, get the data we need build the implant, custom fit to the patient’s unique anatomy. Then we build the implant and perform another surgery to install it.

With Cirq and Airo, we’ll determine exactly where the diseased tissue is before we make the first incision. And we’ll know precisely how to make the implant, based on the 3D scan data. So we’ll create the implant ahead of time and complete both treatment and implant in a single surgery—improving the patient’s recovery and reducing the risk of complications by half.

In other cancer procedures, the technology will help the surgeon know exactly where the diseased tissue is before the incision—and it will also help determine if disease has been completely removed before the incision is closed.

In fact, this equipment is so compact and portable, we could theoretically use it anywhere, even in the Emergency Room. And it is a fantastic training tool: our surgical residents can view exactly what’s happening during surgery, in areas of the body normally hidden from view.

Leading the Way

We’re not just improving surgery for our Hospital Center patients, the work we’re doing will benefit people all over the world. The Hospital Center will play a leadership role in hosting surgeons from other institutions, who can observe our equipment and advance their own knowledge.

We’ve had enthusiastic support from MedStar Health leadership in giving our doctors and patients access to the best possible tools available. Not every hospital will make that kind of investment in leading-edge technology, but that commitment is part of our mission to be the best.

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