Through the 3D Glass

Surgeons performing surgery and a large screen view of surgical site
Ramin Eskandari, M.D., and his team perform an intricate spinal cord detethering procedure on a young child.

A spinal cord detethering case demonstrates how the clearest vantage point protects both surgeons and their patients

by Shawn Oberrath

To see firsthand the advantages of the Synaptive Modus V digital microscope detailed in “The High-Def Surgical Suite,” Progressnotes observed the machine in action during a procedure performed by pediatric neurosurgeon Ramin Eskandari, M.D., and his team.

In this procedure, Eskandari performed spinal cord detethering and fluid pocket release on a 15-month-old child. Tethered spinal cord syndrome is closely associated with spina bifida but can also have other origins, such as lipoma, a thickened filum terminale (a normally delicate filament that supports the lower end of the spinal cord) or a history of spinal trauma. Whatever the cause, as the patient grows and the spinal cord lengthens, the nerves within stretch and can be injured. Surgical intervention releases the tissue attachments holding the cord in place, thus allowing normal movement as the child grows.

While spinal cord detethering itself is not a new procedure, Eskandari’s novel approach uses a powerful combination of coordinated imaging and advanced robotic technology to provide an unparalleled vantage point. This promotes the safest possible outcomes for both patient and surgeon.

Strategy came into play from the beginning — well before the operating room. First, the baby needed to be old enough to safely undergo surgery but young enough that the tethering had not yet done nerve damage.

Health care workers tending to child in MRI machine  
Health care workers tending to child in MRI machine.

Eskandari explained, “Our ability to perform the operation safely increases as they get older, but we also wanted to find a happy medium between doing it early enough and doing it too late. So we picked about a year because that allows us to remove the bony portion of the back of the spine and replace it at the very end, because the bone has grown enough.”

Next, the surgical team went to work on a step-by-step visualization plan. The patient began in the MRI room, where a neuroradiologist marked the exact spot of the operation with a small needle puncture. The location on the back was in an area with no obvious anatomical markers, so having a precisely marked target was essential.

The patient was then moved to the operating room, where a neurophysiologist placed electrodes in planned locations to allow for nerve monitoring throughout the procedure.

This step was crucial according to Eskandari: “This allowed us not only to be safe but also to be appropriately aggressive so we could make holes and cuts where we needed to release the spinal cord, knowing that the neurophysiologist was continuously monitoring the nerves so we didn’t accidentally cut something we didn’t want to.”

With all prep work in place, the procedure began. The surgeons removed a tiny piece of vertebral bone to reveal the dura and then used high-power ultrasound to verify the location.

At that point, Eskandari began working with the Modus V microscope, also called an exoscope. He donned his 3D glasses, opened the dura and then released the spinal cord attachments and the fluid pocket, using the full zoom capabilities of the machine. The instrument can zoom to about 12.5 times normal vision, which far exceeds what even the newest conventional microscopes can manage. Because being a pediatric surgeon means that everything on the patient is small, Eskandari was the first surgeon in the nation to use the exoscope to its maximum capacity in this way.

But beyond mere magnification, the 3D capabilities of the exoscope are where it shines.

“It allows you to see tissue definitions much more clearly and distinguish between different planes of tissues, especially when it comes to things like brain tumor cases or spinal cord tumors. The camera is above you, and the entire operating field is in focus. It’s almost impossible to hit anything or accidentally injure anything because everything is obviously in focus and you don’t lose your peripheral view.”

To complete the procedure, the spinal cord opening was closed, and the bone was replaced by use of an absorbable system.

Eskandari was thrilled to report that the patient did very well after surgery. He said, “The day that the patient left the hospital she was running around in her room and smiling and had no pain whatsoever.”

Not only that, but Eskandari was able to leave the operating room pain-free as well:

“This exoscope has 3D capabilities, so we can put on our 3D glasses and look onto a gigantic monitor in a very ergonomic way and see into the patient without ever having to look down.”

And since fatigue is a very real factor that affects a surgeon’s technical skills as a procedure winds on, a comfortable surgeon is great news for both patients and surgeons.