Counterpoint: Pitfalls of Technology in Neurosurgery
Pitfalls of technology? Perhaps this counterpoint is a losing argument, for in the last 50 years, neurosurgery has been greatly impacted by technology. The microscope added new dimension to operating on small structures, such as aneurysms and complex tumors, thus enhancing operative safety. Computed tomography and magnetic resonance imaging revolutionized diagnosis of intracranial and spinal lesions, reducing the need for more invasive and/or inferential tests such as pneumoencephalography, angiography, cisternography, electroencephalography and myelography. The 21st century has seen increased use of robotics, endovascular treatments and minimally invasive surgery. In fact, technology has advanced medicine significantly in the past 120 years. At the turn of the 20th century, the Roentgenogram gave us a view of the human body no one had ever seen before. Electrocautery allowed us to control bleeding to avoid blood loss at dangerous, life-threatening levels. And electricity, yes, electricity, is the technological advancement that has made most of the above possible. So how can there possibly be any pitfalls in all of this?
Every advance in technology is accompanied by a new learning curve aimed towards mastery. The literature abounds with experiences in new techniques and the process of learning these techniques that inform future success and reduction in related complications. There are few technologies in neurosurgery that can be easily adopted without encountering some troubleshooting along the way. The blessing is that, over time, these issues often diminish, and the true advantage of new technologies promoting efficiency and safety can be fully appreciated and enjoyed, often becoming the standard of care. However, given the philosophy that life is about the journey, not the destination, the process of getting to the point of nirvana can be painstaking, tedious and frustrating.
Technology is always evolving. New things will eventually replace the old in our rapidly developing technological environment. However, relegating our time-honored tools to obsolescence may be counterproductive. Recently during a trauma performance improvement conference, we were surprised to find out that the operating room no longer supplied stethoscopes because they were considered infection control hazards. In our practice environment, the use of the stethoscope after intubation has largely been replaced by the end tidal CO2 monitor – a technology that has increased the safety of general endotracheal anesthesia over the years, preventing anoxic brain injury from inadvertent esophageal intubations. Nevertheless, the basic act of listening to the lungs to assure that they are being appropriately ventilated has been washed away by the notion that stethoscopes are potentially too unsanitary to be of use! There are many physicians rolling over in their graves. Imagine, this sacrosanct tool of the trade a vector for infection; old tried and true technology has given way to fear. However, what if the end tidal CO2 monitor fails in the middle of an intubation or the power goes out? Without that stethoscope, we are back to square one.
Don’t Forget What You Have Learned
Stereotactic navigation has vastly improved in the last 25 years, allowing neurosurgeons to locate deep or small lesions and place intracerebral catheters with more precision. The wide availability of navigation and burgeoning robotic surgery have reduced the need for, as an example, freehand pedicle screw placement practiced by many spinal deformity surgeons. This skill is largely based upon anatomical landmarks and knowledge of the various pedicle angles throughout the spine.
When I was a junior attending, a prominent visiting neurosurgeon spoke on the topic of amygdalohippocampectomies, emphasizing the need to fully know the anatomy of the region to effectively treat the disorder for which this procedure is intended. He warned that navigation devices would truncate our pursuit of anatomical knowledge. This assertion stuck with me for many years, especially when I worked in a municipal hospital where resources were limited and the use of navigation was more selective. As an antidote to the inherent intellectual risks of navigation overuse, I often ask residents to look at the scalp and draw the outline of a tumor’s location based upon our knowledge of the static imaging. We then break out the navigation device to confirm what we know. Moreover, there is little time to set up navigation when evacuating an emergent, life-threatening hematoma. We are therefore obligated to tailor our scalp and bone flap so that we are aiming for the most direct access to these lesions. Once we have opened, we may very well benefit from using technologies, such as ultrasonic guidance, to locate a hematoma not readily apparent from the surface, but we will feel better about ourselves if we have hit the mark by a well-planned incision. Without these mental exercises, our perceptions and knowledge will atrophy.
While CT/MRI has revolutionized the diagnosis of central nervous system disease, allowing diagnostic procedures to become essentially non-invasive, these modalities have all but replaced the neurological examination. In many conditions that we treat, especially in spine, there may be multiple radiographic disease processes, but the basic history and physical examination can go a long way to hone in on which of these processes are in need of attention. Talking to patients and examining them remains crucial, the acts of which do not require any electricity. We must combine basic principles of medicine with technology to devise the best and appropriate solutions for patients’ specific problems. Medicine is still as much an art as it is a science, with clinical judgment playing a prominent role that transcends the technology aimed to help in our decision making.
Electricity Can Fail
So, what about one of the greatest technological advances of modern times: the harnessed and consistent supply of electricity? Thanks to the diligent work of Edison and Tesla, much of our current technology relies upon electricity to keep it going. So what happens when a blackout eliminates our ability to supply electricity to our gadgets, or when the only available drill breaks down during the opening of the skull?
Mechanical and electrical devices do fail from time to time. We need to train residents on traditional methods to open a skull without the need of an electric or pneumatized drill. Residents in training can benefit from knowing how to use the Hudson Brace and the Gigli saw. Advances in computer use and capacity have accelerated technology asymptotically. The light board and x-ray film have been replaced with a flat-screen television monitor that digitally displays images. But, in our digitally-directed world, what do we do when a computer, cable or internet connection fails so that we can no longer view those images, especially during the vital surgical “time out” or at a juncture of the case when we need to refer to the imaging to assist our intraoperative judgment? Do we print them out and paste them on the wall? I have certainly had to do this.
Technology Isn’t Everything
Medscape recently published the 12 worst medical technology dangers, among which were (1) desensitizing alarm fatigue for monitoring devices; (2) radiation exposure from CT and radiotherapy machines; (3) cross contamination from flexible endoscopes; (4) failure to pay attention to the connectivity of new devices; and (5) surgical fires (especially with the use of electrocautery). (http://www.medscape.com/features/slideshow/tech-dangers). It is important for all of us to understand the technology available to us and utilize it in the best and safest manner possible. The onus is also on the manufacturer and the hospital/end-user to maintain our equipment, connections and power supplies in top shape so that the failure rate is minimized.
In the U.S., we are fortunate to have access to some of the most advanced technology in our specialty. However, not all hospitals have the same financial resources, and the conservation of these resources in municipal and safety-net institutions can retard the adoption of new technologies. Surgeons may, therefore, become adept at maintaining safety, regardless of imposed limitations, when consistently using basic, sound surgical skills. Surgeons in austere environments are often obliged to use ingenuity to substitute for the lack of available technology, but a growing number of graduating trainees will not likely be able to function under such circumstances unless specifically trained to do so.
While technology drives advancement in improved diagnosis and treatment of many conditions, let us be mindful that technology does come at a cost. Such costs can include a steep learning curve with longer times to mastery, reduction in basic anatomical and clinical knowledge gleaned from study and interaction with our patients and weakness in adapting to environments where our technologies are immediately unavailable. We must continue to teach our residents and students the importance of the neurological and physical examination, the need to fully know and understand neuroanatomy, the ability to be flexible and “think on their feet” and the knowledge of alternative surgical techniques. Technology must serve as a complement to our basic skills and not replace them.
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