Have there been any interesting developments in neuro or spinal surgery?
Not so much. The really big steps in surgery happened 50–60 years ago – safe anaesthesia, the ability to anticoagulate patients so you could operate on the heart without the blood vessels clogging. That completely changed surgical intervention.
In the last 10 years, the biggest change has been in vascular procedures. Instead of doing open operations and cutting into vessels, we now use catheters and modern plastics to perform virtually any procedure through a blood vessel in the wrist or groin, guided by an image intensifier or X-ray machine. That’s completely revolutionised that sphere.
But in the brain and spine, we haven’t got that ability. We’re still doing procedures that are essentially similar to the ones we were doing 30, 40, even 60 years ago. If you break it down, there are really only two operations in the spine – decompress the spinal cord or nerves, and fuse bones together. All surgeries are a subset or combination of those two.
There are a few rarities – disc replacement surgery, spinal cord stimulators for severe chronic pain – but the rest are very straightforward procedures. What’s constantly evolving is our ability to do them better, safer, and through smaller incisions.
The more we can see internally without having to expose it, the less we have to destroy or disturb normal tissues. In the pre-MRI era, we weren’t sure what was down there. Now, with MRI scans, we’ve got such an accurate surgical map that we can say, “I need to go there to remove something that’s this big and just down there and around the corner.”
We’re doing the same procedures we did 30 or 40 years ago, but through incisions that are dramatically smaller. Our tools – rongeurs and drills – are already 1 millimetre in size. I’m not sure we can make them any smaller. There’s a limit to how small the exposure can be, because you’ve got to be able to get the tools in safely.
The moment you can’t, you’re talking about doing surgery blind. And when it involves the brain or spine – where there’s no margin for error – that’s not acceptable. If a structure is inadvertently damaged, it’s irreparable. So I think we’re almost at the limit of what we can do – unless perhaps we get robots involved.
