It’s 1995, Seattle, Washington, and I am watching my first spine surgery as a senior medical student. To be scrubbed in a neurosurgical operation was at the time the culmination of a life’s dream. The patient had presented with pain and numbness from pinched nerves due to a spinal canal narrowed by bone spurs and arthritic change from age and hard use.
Nonsurgical treatments had failed, and he was undergoing the best surgical option at the time. After making the incision and getting to the back of the spine, the neurosurgeon removed the bone in the back, along with the joints, and then removed the disc at the front of the spine. Now the nerves were completely decompressed. The spine, however, was also unstable. To stabilize the spine again, he placed a metal graft or “cage” to replace the disc and added four screws and two rods.
It was a startling realization as to what we were doing. The patient hadn’t come in with an unstable spine, but in order to “unpinch” his nerves, we had just made his spine unstable and then we had to fix that with screws, rods, and a spinal fusion. Watching this operation, with its familiar surgical instruments like rongeurs, punches and mallets, showed that despite decades of medical advancements this was still the best we had for spine surgery.
In his book “Better,” Dr. Atul Gawande writes of five suggestions of “how one might make a worthy difference, for how one might become, in other words, a positive deviant.” The last of these five suggestions is “change.” He writes this about change: “Be willing to recognize the inadequacies in what you do and to seek out solutions. As successful as medicine is, it remains replete with uncertainties and failure. This is what makes it human, at times painful, and also so worthwhile.”
Watching that spine surgery years before reading Dr. Gawande’s book, the thought struck that there had to be a better way to do what we were attempting. A nerve that was 2 or 3 millimeters in diameter was being pinched inside a tunnel that should be a comfortable 4 to 5 millimeters, but had become constricted to less than 2 millimeters. A millimeter problem seemed to require a millimeter solution.
There was a beauty and elegance to that line of thinking that seemed to me to reflect the beauty and elegance of wonderful surgical solutions. The next week, I started looking for other options. Advanced research in the mid-1990s at the University of Washington, funded in part by Defense Advanced Research Projects Agency (DARPA) grants, was leading the way in ultrasonic technology development, and this seemed to be a potential solution.
By 2001, the technology was approved by the U.S. Food and Drug Administration (FDA) for brain and spine surgery. We started using the technology in surgery of the brain the following year, and by 2007, we had started using the technology and the microneurosurgical techniques in spine surgery.
Think of an ultrasonic toothbrush. The vibrations take plaque off one’s teeth. Advance the concept and shrink the tech, and now you have a 1-millimeter device that vibrates at ultrasonic speed sonicating and removing millimeter by millimeter whatever is compressing a nerve. It’s a millimeter solution to a millimeter problem.
And because one doesn’t have to remove all the bone, disc, or joint that provides structural support to the spine, the spine is not destabilized and spinal reconstruction or fusion is usually unnecessary.
Millimeter solutions to millimeter problems, using advanced technology and techniques. Attempting change to do better. To be a “positive deviant” for our patients and our community.