July/August 2008

A Messy Art

A neurosurgeon explains how she manages to cope with the newest technologies for brain surgery.

By Katrina S. Firlik

Katrina S. Firlik Credit: Steve Moors

Multimedia   Katrina Firlik talks about using technology in neurosurgery.

A few months ago, I sifted through a stack of junk mail on my desk--"Neurosurgery Opportunity in North Dakota," "Advances in Acromegaly," "Katrina, Join Us in New Orleans!"--and tossed most of it. At the bottom of the pile was a big, floppy, colorful 2008 calendar from medical-device maker Medtronic. This I lingered over for a moment, then saved.

Medtronic's navigation business, which creates technology that helps surgeons explore the human body, is headquartered at the foot of the Rocky Mountains. The calendar promised "stunning imagery from Colorado and stunning innovation from Medtronic." Take September, which features an "autumnal sunset in a thriving aspen forest near Durango, Colorado." This image is paired with a photograph of a piece of surgical technology that gets its own loving description: "Medtronic cranial navigation pointer probes provide an enhanced patient registration experience for a thriving neuronavigation practice." I see the connection: thriving forest, thriving practice. I'll take one of those pointer probes, please.

Where to hang this calendar, though? September might provide a pleasant piece of art for my office, but August, which features a blurry and bloody close-up of what I believe is probably a brain tumor as seen through a surgical microscope, might be pushing it. ("Doc, that calendar over there: what exactly ... ?") I figured that my kitchen was out, too.

There was a time when displaying such images made perfect sense to me. Years ago, thrilled to have been accepted to a neurosurgery residency program, I contacted a medical-device manufacturer to get my hands on a poster featuring detailed photos of aneurysm clips, which are used to close off a bulging area in a weakened arterial wall to prevent a hemorrhage in the brain. I had seen such a poster once before and was amazed by the clips' variety of configurations and sizes. These small titanium devices are gems of form and function, perfectly engineered for their specialized task. Having finished medical school, I was about to embark on the seven-year training required to become a neurosurgeon. I wanted that poster.

I am surely not alone in loving the tools of my trade, nor in finding them physically exquisite. Surgeons are the natural technophiles of medicine, and neurosurgeons rely at least in part on especially advanced technologies. But there is a flip side to the wonder I feel, and it is this: each new technological advance promises a fresh cause for cursing in the operating room. Although the details change from decade to decade, and even from year to year, the source of consternation remains constant: the fiddle factor. It is, in essence, the same problem that arises with laptops, cell phones, digital cameras, and home theater equipment. When the ­complexity of your home theater system gets the better of you, though, it just means that you might not get to enjoy tonight's basketball game in surround sound. In my job, the fiddle factor can have more serious consequences. This, after all, is brain surgery.

Measure Twice, Cut Once
My profession has come a long way since the dark early days of exploratory surgery. Before the advent of computed tomography (CT) in the 1970s, a surgeon was often guided by clinical judgments about as vague as "It's got to be on the left side." Things got even better in the 1980s, with advances in magnetic resonance imaging (MRI). And in the decades since, neurosurgeons' ability to target a lesion, such as a tumor--to figure out where it is in the brain, and then to actually find it at the time of surgery--has been aided dramatically by advanced imaging and the technology it has made possible.

The technology that always seems to impress visitors to our operating rooms is our navigation equipment. ("Navigation" sounds better than "computerized frameless stereotaxy," so I will stick with that term.) Simply put, navigation technology affords us something like x-ray vision during surgery. With a specialized wand (or "pointer probe," our Miss September), we can point to a specific location on or in a patient's head, and the system will show us--we hope--the corresponding spot on a previously obtained MRI of the patient's brain. It works well most of the time, but like almost every other technology we surgeons use, it has a few kinks and causes a few headaches.