SET UP FOR SUCCESS Complex spine procedures are never easy, but real-time imaging reduces some of the challenge.

Image guidance and enhanced CT scans have made patient care more personalized and precise, says Clare Tempany-Afdhal, MD, BAO, BCh, professor of radiology at Harvard Medical School and chair of radiology research at Brigham and Women's Hospital in Boston. But will working with near-real-time images of patients' anatomy become the standard of care? "Of course," she says, as if the question is rhetorical. "It's inevitable. We're eventually going to have high-performance imaging platforms everywhere."

Some surgeons who perform intricate procedures already think state-of-the-art imaging is essential, and seek out facilities that realize imaging's future promise is rapidly becoming today's reality.

Powerful drivers
KentuckyOne Health in Louisville recently added an integrated OR to its neurosurgery service line, which includes complex spine procedures. "We're involved in educating the next generation of surgeons," says Warren B. Boling, MD, FAANS, FRCSC, FRACS, a neurosurgeon in the health system. "Part of that responsibility is to have high-quality videos immediately available during surgery."

Dr. Boling says enhanced intraoperative imaging has been the driver of surgical advances. "As computers get faster and faster, and technology can fit in smaller boxes," he explains, "we're able to do amazing things with imaging."

Imaging upgrades in the OR can be used in real time and integrated into image-guidance platforms. "That means we can do more complex procedures through smaller openings to expand the horizon of minimally invasive surgery," says Dr. Boling.

"There's no doubt the speed of transmission and ability to move large data sets have improved enormously," says Dr. Tempany-Afdhal, who's also the co-director of the National Center for Image Guided Therapy. "That's moving the whole evolution forward. It takes extraordinary software tools to manage the images and navigate through them."

Surgeons are comparing images of anatomy taken a month before surgery with updated images taken in the OR, so they're fusing one data set with another, says Dr. Tempany-Afdhal. "The technologies are becoming very exciting, with lots of experts working on innovating imaging's potential."

She says more surgeons are basing their movements on 3D maps of a patient's specific anatomy to see what they need to resect, ablate or treat, marking a huge advantage over 2D white-light surface views.

Dr. Tempany-Afdhal is certain that enhanced real-time imaging will allow for a more personalized approach to patient care. "Instead of storing images in a file back at the surgeon's office or displaying them in a view box in the back of the OR, they're used in real time," she explains. "You don't treat every patient the same way. You treat them based on their specific anatomy and condition. The whole approach is changing."

The aim is to improve surgical outcomes — total cancer removal, total tissue resection — in a quicker, safer, more effective way, according to Dr. Tempany-Afdhal. "There's lots of ongoing research trying to show that improved imaging accomplishes those goals," she says.

Streaming images to recording devices lets surgeons use images before, during and after surgery, says Dr. Tempany-Afdhal, who notes that although sensitivities surrounding HIPAA concerns need to be properly managed, recording intraoperative video offers "amazing opportunities for learning and teaching best practices."

SHOWING THE WAY Surgical navigation will become the standard of care during intricate cases, some experts believe.

Getting it right the first time
Lisa Stevens, RT(R), MHSA, director of cardiology and radiology at OSF St. Joseph's Medical Center in Bloomington, Ill., says her hospital needed to add a sixth OR to expand its surgical capacity, and decided to invest in a hybrid suite to accommodate complex cardiology and spine procedures.

When shopping for real-time imaging platforms to add to the room, they looked for platforms with high image quality that were easy to use and able to integrate with the room's surgical table.

The C-arm is mounted to the ceiling so it can rotate around the patient. It features low-dose software that freezes captured images and creates road maps of the patient's anatomy with as few images as possible to reduce radiation doses by as much as 40%, compared with the hospital's previous-generation imaging technology.

"Real-time imaging leads to safer, less invasive surgery," says Ms. Stevens. "Targeted approaches and near-real-time feedback avoid waiting for other staff or equipment to confirm placement of hardware or the effectiveness of surgical interventions."

Using a patient's anatomy to guide approaches is where surgery is heading, she says. "That decreases infections and turnaround times, and patients don't have to come back for reoperation, because outcomes are confirmed during the initial procedure," she says. "It's a clear benefit to patient safety."

The hospital is also investing in an O-arm, a donut-shaped unit that takes standard X-rays, but also captures 3D images of anatomy. The unit opens up into the shape of a conventional C-arm to capture 2D anteroposterior (AP) and lateral images. When closed, it scans completely around the patient for 18 to 23 seconds, capturing 3D images that it sends directly to a surgical navigation system that helps guide surgeons' movements. The 3D images are captured with a single scan, which helps surgeons operate faster and limits the surgical team's risk of radiation exposure, explains Ms. Stevens, who says spine surgeons use the technology to know for certain that they're operating at the correct vertebrae level or that screws have been properly placed.

Returns on investment
Improved patient care is certainly a concern, but surgical service lines also need to turn profits. Don't discount the potential bottom-line benefits of using real-time imaging to perform more efficient surgery.

"By performing complex surgeries more quickly, you cut down on infection risks and improve the quality outcomes we have to report and get paid on — or not get paid on," says Ms. Stevens.

"There are several drivers for the hospital," explains Dr. Boling. "One is to get surgeries done faster, so there's better utilization of the facility. The others are better outcomes and higher quality of care and fewer complications." As he points out, reimbursement dollars are now attached to quality-of-care measures.

Reducing the length of procedures and a surgery's degree of invasiveness could get patients (and surgical teams) in and out of operating rooms faster, says Dr. Tempany-Afdhal. Could that lead to significant cost savings? "That's the theory," she says. "I certainly hope that it will."

Current imaging technology might be cost-prohibitive for some facilities. Not every surgeon needs image guidance, and not every facility should invest in it. At least, not yet. "Older, very experienced surgeons have learned how to do procedures without a lot of information," says Dr. Tempany-Afdhal. "Younger surgeons will learn much faster with the information."

But she says it's important to consider the bigger picture. "Reoperation rates will go down and readmission rates will decrease because surgery is performed correctly the first time," she points out.

Besides, computers and high-definition televisions were expensive when they first hit the market, weren't they? Can we live without them now? It's the same story with imaging upgrades, says Dr. Tempany-Afdhal. Start-up costs will eventually decrease, but until then there will be early-stage adopters and late-stage adopters, with individual facilities at different stages of the spectrum.

Ms. Stevens says the latest technology is expensive, but her hospital's administration realizes there's benefit to investing in it, notably more exact approaches to anatomy and confirmation of intended outcomes before patients leave the OR.

She says the initial savings may be soft, but the hospital understands the numerous benefits they'll eventually realize, not the least of which is staying on the cutting edge of care and attracting forward-thinking physicians.

"Our investment in imaging technology helps attract innovative surgeons," she adds. "In a lot of way, it's about keeping up with the Joneses."

FRONTLINE FEEDBACK
Why Surgeons Love Image Guidance

ROOM UPGRADE New integrated ORs at KentuckyOne Health in Louisville offer the latest in intraoperative imaging technology.

Warren B. Boling, MD, FAANS, FRCSC, FRACS, says image guidance gives surgeons the confidence they need to know where they are in the anatomy in relation to critical structures. "If you bring more data into the operating room to perform more minimally invasive surgery, procedures are shorter, there are fewer risks of infection and patients recover faster with fewer complications," says Dr. Boling, who's a neurosurgeon at KentuckyOne Health in Louisville. "That's really the revolution that's taken place."

Can the latest imaging technologies help you operate more aggressively? Dr. Boling shies away from using that term. "Let's just say we can accomplish more complete surgery," he says, explaining that real-time imaging lets surgeons treat targeted anatomy and confirm they've accomplished intended tasks.

He says image guidance provides important information about where structures are located, without which some complex surgeries cannot be performed safely. He says spine reconstructions and decompressions have been completely transformed by image guidance, allowing for more involved repairs through small percutaneous openings.

"Just his morning I operated on a patient with a herniated lumbar disc," says Dr. Boling, on the day we talked. "It was a straightforward surgery, but it's now able to be done through ports that leave only a Band-Aid-sized scar. We remove the disc herniation and patients go home the same day."

Image guidance lets Dr. Boling place rods and screws during larger reconstruction surgery through the same small percutaneous openings. "Using sophisticated image mapping technology, and having the expertise to use it, is essential," he says.

Dr. Boling believes complex surgery shouldn't even be attempted without imaging technology to map surgical pathways and confirm successful outcomes. "Nowadays, I think image guidance is the standard of care," he says.

— Daniel Cook