Cervical, spinal, disc and lumbar diseases. Tumors of the nervous system and pituitary gland, aneurysms are today increasingly treatable thanks to the refinement of diagnostic imaging and surgical techniques. An example? Computerized and 3D navigation of the patient’s brain and spinal cord, before, during and after surgery. These are some of the new frontiers of modern neurosurgery. Spinal and brain surgery assisted by CT or intraoperative magnetic resonance and by ‘computerized navigation’ were certainly the first and most important application of computers to surgery, but since then there have been many advances and today the level of precision is enormous. in the face of less and less invasive interventions. To take stock of the situation is the 70th National and International Scientific Congress of the Italian Society of Neurosurgery (Sinch) which takes place in Milan from 14 to 16 October with the participation of over 500 experts.
The use of new technologies in neurosurgery
According to data from the Italian Society of Neurosurgery, 50,000 neurosurgery operations take place every year in Italy (15,000 in Lombardy alone). There are many areas in which neurosurgical advice is required but new technologies come into play especially in some delicate phases: “They are mainly related to pre-operative and intraoperative 3D imaging of the brain and spinal cord”, he explains. Maurizio Fornari, head of the Cranial and Spinal Neurosurgery Operating Unit of Humanitas and president of the Milan Congress together with Franco Servadei. “But we also have ‘computer assisted’ 3D navigation systems to carry out the surgery guided by the computer itself and then highly refined systems to functionally monitor brain activity during the operation with bioelectric modality”. This monitoring is continuously associated with ‘computerized anatomical navigation’. The association of these systems allows the neurosurgeon to identify in advance and in a computerized way the anatomical and functional characteristics of each brain and medullary structure treated surgically.
Minimally invasive spinal surgery
Among the most widespread interventions in recent years there are those of minimally invasive spinal surgery which aim to stabilize the vertebrae and spinal joints or to relieve compression of the spinal nerves often due to conditions such as instability, arthrosis, herniated discs, scoliosis or spinal tumors. And also in this field there have been many innovations: “Today we can acquire the Tac images in 3D while the intervention is in progress and then also in this case it is possible to manage the intervention with computerized navigation. Thus, we can manipulate with absolute precision not only the visible structures but also those made identifiable by virtual reality possibly implemented by augmented reality ”, explains Fornari who is a pioneer of computerized spinal neurosurgery. The result is an enormously more precise and less invasive surgery.
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Brain tumor surgery
Technology is also making progress in the surgery of brain tumors, allowing the pathology to be tackled more effectively both intra and postoperatively. “We have direct mapping methods of brain functions with the patient awake and cooperating,” he adds Federico Pessina, head of Humanitas cranial surgery. “By inhibiting different motor, linguistic or cognitive stimuli we are able to identify with extreme precision the associative bundles responsible for normal social life, maximizing surgical resection and minimizing post-operative deficits”. Innovation also enters the operating room: “We can count on molecular diagnostic methods on the masses that we remove in real time, thus being able to customize the type of surgical removal according to the characteristics of the individual patient and the pathology”, continues Pessina.
Research in Neuroncology
Not only. Subsequently techniques of increasing precision and refinement applied to radiotherapy allow a ‘surgical sterilization’ of the operative foci. “A new frontier – explains Pessina – is represented by the application of these techniques even before operating the patient in order to minimize the risk of tumor recurrence or spread to the contiguous areas. All these data have allowed us to implement research in neuroncology, laying the foundations for the development of new therapies based on the study of the immunological microenvironment from a lymphocytic, macrophage and dendritic point of view “.
Robotics in the operating room
The advent of robots in the operating room is also making neurosurgery more efficient. “We have recently created a working group with the robotics department of the Politecnico di Milano,” says Fornari. “The robots available for neurosurgery consist only of systems for programming anatomical and surgical trajectories in three dimensions in a more precise way”. Instead, the use of robots similar to the famous Da Vinci in use for many years for thoracoabdominal surgery which allows a fine micromanipulation of the tissues with the aid of minute remote controlled robotic arms is only in the initial experimentation phase. “The difficulty in carrying out this passage – continues Fornari – is linked to the small size of both the access doors and the neurosurgery work space”.
When the robot replaces the surgeon
But does the patient trust when the robot replaces the surgeon’s hand? “In reality – replies the neurosurgeon Fornari – patients have a great expectation from robotic surgery because they hope for the infallibility of the machines. It is a fair expectation and is shared by neurosurgeons. It is an objective that can be achieved when an adequate technology and an equally adequate competence are developed on the part of the user surgeons “.
The training of neurosurgeons
That of the formation of the next generations is a deeply felt theme. “Italian neurosurgery has a great past, but today more than ever there is a need to update because scientific and technological changes are much faster and this requires a silent revolution or rather a renaissance”, he explains Paolo Cappabianca, president of Sinch and director of Neurosurgery at the Federico II University of Naples. “Currently the members are about 600, but we have made a big investment in young people. It takes 20 years to train a neurosurgeon well ”, continues Cappabianca. “We now have over 250 neurosurgery specialists who in the next few years will be ready to give their best as happens in the USA where at just 30-35 years old they already reach the peak of their careers”. To strengthen innovation in this field, Humanitas has already added a new pioneering degree course to the traditional degree course in medicine (Hunimed) for two years. “It is a Medicine-Engineering (Medtech) course carried out in collaboration with the Politecnico di Milano which is enjoying an extraordinary consensus. Technology is the best colleague for the neurosurgeon, ”explains Fornari. And the ‘pink quotas’? “More and more women are accessing surgical specialties in Italy until they become a majority compared to men. There are now many in the Faculties of Medicine and in the Specialty Schools in Neurosurgery. The access tests to medicine and to the various Specialty Schools have rewarded the merit of women ”, concludes Fornari.
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