July/August 2008

A Messy Art

Continued from page 8

By Katrina S. Firlik

In my mind, however, it's not so clear whether the minimally invasive approach is a plus for smaller, less involved spine cases. Take a typical lumbar microdiscectomy, in which a small window of bone is drilled into the spine in order to extract a fragment of disc pressing on a nerve. This is the most common operation that neurosurgeons perform.

The senior surgeon who taught me the traditional approach to this surgery showed me how to do the operation through an incision measuring about an inch. He was so proud of his small incisions that he would take a picture of the large fragment of extracted disc held up next to a ruler, which was placed in line with the incision. He would give this photo to the patient after surgery. This was quite effective for word-of-mouth marketing. ("Wait, you need disc surgery? Go to my guy. Take a look at this!") I became quite comfortable and efficient with this technique, and I found that most patients did not have significant postoperative pain at the incision site.

As minimally invasive spine surgery became popular, as patients started to ask for it, and as instrumentation companies pushed their tools for both the big and small cases, I felt obligated to try it. What I found, though, was that the juice wasn't worth the squeeze. All of a sudden, what had been a relatively pared-down operation required more instrument trays in the room, a nurse familiar with the new tools, a large specialized retractor that had to be bolted to the bed, an unwieldy fluoroscopic "C-arm" machine that seemed to get in the way, and (because the new technique involved fluoroscopy) a heavy lead apron that I had to wear for at least the first part of the surgery.

Spine surgeons have started to realize that a minimally invasive discectomy actually seems to increase the likelihood of one particular complication: leakage of cerebrospinal fluid. That's because the surgeon must use a rigid and narrow retractor, which makes it difficult to achieve unfettered access to all the necessary anatomy, especially when the surgeon is still on the steep part of the learning curve. As for the prospect of reducing postoperative pain, an original selling point of the new approach, I have not been impressed. I will admit that the new tools enable surgeons to operate through an incision that is slightly smaller than my usual inch. Is anyone excited?

For all my griping, I am inspired by the general direction of innovation in surgery. I can't help believing that the answer to the fiddle factor is better technology, not less technology: after all, the innovative leaps in other fields leave medicine far behind. The most high-tech equipment available to the brain surgeon pales in comparison with the technology onboard a fifth-generation fighter jet, or in a modern nuclear power plant.

If we can catch up a bit, it will be fascinating to see what's in store for neurosurgeons of future generations. But we should be careful what we wish for. Just as technological advances in nuclear plants and fighter jets try to maximize safety and efficacy by minimizing (or even eliminating) the human element, we should realize that the ultimate advances in surgery will take aim at perhaps the most fickle tool in the operating room: the surgeon.

Katrina S. Firlik is a neurosurgeon in Greenwich, CT, and the author of Another Day in the Frontal Lobe: A Brain Surgeon Exposes Life on the Inside.