On the Future of Neurosurgery

I want to take you to the operating room of the future. In the OR, the surgeon makes many decisions every second, and these decisions are primarily based on 3d anatomical knowledge,  experience and surgical intuition. The surgeon has some options to support decisions with image guidance. To do this, he or she often has to remove the microscope, pull out all his instruments and look at a screen the so called neuronavigation system, which was introduced back in the 1990, 30 years ago. He or she has to translate the 2D data on the screen to the real world, 3D patient, which makes accurate localization of the target – let’s say a tumor- sometimes challenging. Importantly the surgeon loses momentum, focus and attention during surgery.

In the future OR I envision, surgery will be performed somewhat differently. It is AR navigated, more data driven. The surgeon will have instant access to different imaging modalities, MRI, CT, or 3D holograms which can directly be overlaid on the patient, without the need for a monitor. The surgeon will be able to visualize vitals and other information of the patient instantly within his field of view. Some recent speculative authors have suggested that robots, AI algorithms, will perform surgery in the near future. I don’t think that will happen any time soon. A more realistic future perspective is that AI algorithm will support decision making of surgeons; data driven surgery. The surgeon will be able to overlay accurate AI-predictions on tissue to decide if that last part in the resection cavity is, or is not residual tumor, which is often difficult to see even for a trained surgical eye. It will guide the surgeon trough the safest trajectory to the target, based on calculated risks, thereby minimizing the risk for complications during surgery.

At the Erasmus MC, together with the depts. of radiology and neurosurgery, we have set the first steps to realize a future OR with AR navigation. We have tested the feasibility and accuracy of a wearable augmented reality device – in our case the Microsoft Hololens- during brain surgery on 25 patients. We converted MRI images of brain tumor patients to holograms and overlaid these holograms with the physical head of the patient. So the surgeon could see the brains and tumor of the patients through the skull, instantly by looking at the patient. This new technology proved to be pretty accurate when compared with the neuronavigation system and surgeon reported an improved focus during surgery.

This is one of the first scientific papers on this topic presenting quantitative outcome measures. We did this study pragmatically (started in 2016) and presented this idea, this proof of concept, to the neurosurgical community to accelerate AR research around the globe. I am happy to see that research groups in the Netherlands, Belgium and the United States are also working on this topic. Recently, Brainlab (a neuronavigation company) has announced a collab with Magic Leap (AR company) which shows the interest of big companies and the direction we are heading in the future. Big companies entering the scene will accelerate AR research/usage and help neurosurgeons to grasp the significance of AR. Indeed, more research on this topic within the field of neurosurgery is needed.

I gave this talk at the ESNR Sept 2018 in Rotterdam (last paragraph was added for this blog).

Link to our paper: https://www.ncbi.nlm.nih.gov/pubmed/30257298

https://www.brainlab.com/press-releases/brainlab-and-magic-leap-partner-in-digital-surgery/