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Trauma Room One - Season 2 Episode 7
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00:00is an operating theater like no other
00:04doctors are the pinnacle of their profession ah big nest of vipers that's all totally abnormal
00:15fight to save lives are you all right buddy a bit of pain there yeah spit down my face
00:22in neurosurgeon being able to change lives for the better there's no other job that i'd rather
00:27be doing it's high-stakes surgery this is amazing i've not seen anything like this before ready
00:34go if you cause an injury to the brain or the spinal cord you can't repair it that's it forever
00:41using groundbreaking technology making life or death decisions oh yes a sea of blood if we don't
00:50do anything should die he needs to wake up i think it's gone well it feels really good
00:56i love it when a pond comes together this is trauma room one
01:03it's 8 a.m the walton center in liverpool a patient is inbound
01:1964 year old bruce has a broken back
01:27still a bit vague i mean so i go into the kitchen got the cup ready and put the kettle on and then
01:38i just passed out i can't remember much more after that then i woke up but i tried to move
01:45and uh it was just so bad the pain i thought i've done something to myself here i mean so much pain
01:53it is really bad
01:55surgeons at the walton center treat around 170 people with broken backs every year
02:04bruce has a pre-existing medical condition this is a strange uh condition called ankylosing
02:22spondylitis this is his ct scan it's almost like the spine has all started to merge together like a
02:29like a melting candle almost the bones are fusing together but also they're quite quite thin
02:36now the issues with this is that if you were to suffer a fall or an injury which he has and it can
02:42lead to a fracture of those fused bones and what we're interested in is this bone down here he's
02:49broken the bone there so what we're going to do today very simply is essentially to put in some
02:53scaffolding around the spine and stabilize his back it's a complex procedure one that calls for a piece
03:03of cutting edge kit we're very lucky here at liverpool's walton center that we have a state-of-the-art
03:13surgical robot literally designed for this purpose before the robot spinal surgery would involve doing a
03:21very long incision stripping off the muscles there's going to be a lot of blood loss associated with
03:25that and what the robot allows us to do is to scan the patient with a ct scan to reconstruct that data
03:32in the robot and then we can just make very small skin incisions to sneak in and therefore we don't
03:38lose the blood that we would see in open surgery but before surgery can begin there's a challenge
03:48so there are some issues that we encounter with this condition one is the shape of the patient
03:53the patient's very very hunched over this gives us airway problems and the positioning problems
03:58so actually putting him onto a table is going to be a difficulty for us and so we're going to
04:02be positioning very carefully to support his shape so there are some real technical challenges
04:07just to get into the patient onto the table asleep
04:12the operation requires two surgeons
04:15that's the risk isn't it you don't want to break his neck on positioning him
04:19working alongside mr carlton bland is consultant neurosurgeon mr matthew stovell
04:25make sure his body's good his head's good and and then when we're happy with that yeah then we
04:30need to bed and die there are stories of patients with ankylosing spondylitis with this very marked curve
04:36actually sustaining a fracture during positioning okay it takes the whole team to move bruce with
04:44absolute precision even the smallest shift could damage his brittle spine even more
04:50ready steady slide okay and when we roll him we're going to go real slow real gentle okay yeah one two three
05:01okay okay that's good good good yeah great thank you i'm happy with how it's going i mean
05:15luckily the setup we've got here has been able to accommodate this curvature and actually
05:19we've got quite a nice position so i'm pleased with that so far so good
05:28with bruce secure reference markers are fixed to guide the robot
05:35that does feel quite strong actually let's go with that
05:37a ct scan maps the spine
05:49it's really rubbish isn't it around the fracture i think it's moved it's open a bit yeah
05:54but it reveals a problem there's a fracture line there so you will actually cross a fracture line
05:59what we're seeing here on the ct scan the fracture actually just by positioning him has opened right up
06:04and that gives us a surgical problem because we have to decide how we can capture that broken bone
06:11which obviously is moving around so we're just seeing if it's technically possible
06:15we'd have to check the angles of all the screws that we're planning there yeah
06:25the walton center in liverpool is one of the country's leading specialist hospitals for neurology
06:39and neurosurgery
06:44here teams take on the most complex and sometimes the most mysterious conditions
06:49it is not uncommon to find patients that are a mystery many people would expect that an mri scan
07:00for example would give you a diagnosis um sometimes the mri scan just tells us that there's
07:05something there that shouldn't be there and we don't know exactly what we're going to find until
07:10we go inside and explore 64 year old keith has unexplained symptoms that have steadily been getting
07:20worse looks like i walk on wooden stilts because i just can't bend my legs the muscles that tight
07:27but they go hot or very cold and they just i just walk along and sometimes i might trip
07:33i've done physio pilates even had a massage on them she's pressing on the back of me
07:42calf muscle quite strongly and i said are you titling me with a feather he said no she's pressing
07:47pressing really hard are we ready to rock and roll tasked with trying to diagnose and fix keith
08:02is consultant neurosurgeon mr sean subawali most surgeons are control freaks we like to have
08:11as much control over the situation as we can we like to plan as far ahead as we can so that we don't
08:16have surprises in this case we're going to have a surprise because we don't know what it is that's
08:21causing the problem it seems to be an issue in keith's spinal cord the area that transmits nerve
08:32signals to his legs now if you look at the mri scan here is the spinal cord this black structure here
08:40either side of the spinal cord you've got the spinal fluid now as you follow the spinal cord down you
08:45can see that it's moving more and more forward in terms of its position and inside the spinal cord you
08:52can see this white area here there's an abnormality there
08:55some sort of mass hiding within that fluid space so we can see the effect of it but we can't see what
09:04it is so we'll find out once we open him up off we go
09:13the first cut exposes the back of keith's thoracic spine the middle part of the backbone
09:18so the first thing that we need to do is to dissect the muscle you see
09:29put some retractors in which keeps everything open so we've got a corridor that we can work down
09:35do we have the bone scalpel
09:37to reach the spinal cord mr subawali will carry out a laminectomy removing a section of bone in the vertebrae
09:49we can remove the bone
09:59okay get the microscope in and we'll be able to see the spinal cord
10:08okay so now we have our dura so that's the outside tough lining of the spinal cord
10:16what's going on here zoom in a bit please
10:25a close-up of the dura reveals an abnormality
10:31feels empty doesn't it the fluid space beneath has collapsed
10:37that's not normal to reach the problem mr subawali must cut deeper it's a very dangerous operation to
10:47perform you're very close to the spinal cord the slightest slip of the hand could paralyze the patient
11:04the walton center in liverpool treats around 450 brain tumor patients every year
11:14one of them is 62 year old linda i was noticing that my speech wasn't as
11:28that this pattern of speech was a bit strange i went to the gp he sent me for emergency ct scan said
11:36um you have you have something in your head
11:50okay hi linda my name's jess i'll be looking after in here okay today professor andrew broadbelt will
11:57carry out a craniotomy to remove the tumor but to do so he will wake linda up during the surgery
12:05okay linda hope it goes all well thanks very much with linda her tumor is near her speech area
12:12and certainly we know that if you are aggressive with these tumors that patients can lose the
12:20ability to speak afterwards that can be for a short period of time or permanently and one way of trying
12:27to reduce that risk is we wake them up take as much down as possible whilst preserving the speech
12:37if we look at her scans so this is her as if we cut the top of her head off and this white thing is
12:43a tumor we think this is an aggressive type of brain cancer something called a glioblastoma
12:49and if we can take everything out that looks abnormal on the scan all that white stuff
12:56then she'll do better with treatment
13:01a glioblastoma is the fastest growing brain tumor we good yeah we okay to start
13:07yeah self-retaining retractor please linda's operation is urgent thank you forceps please
13:25tumor's all under that
13:29this is the bit i'm worried about speech around here drill please
13:38next step remove the skull and we use like a little jigsaw to make a hole in the bone
13:45to create an access window leading to the brain
13:54so there's our bone a little bit of bone
13:58there you go
14:00this is the area i'm worried about our speech area is all here tumors all in there
14:08and i really want to go in here to get into it but it'll depend if this is speech then i'll have
14:13to come further forward further higher up and find somewhere that's safe
14:20the tumor sits just millimeters from the function that controls speech
14:25to avoid damaging it the team will now bring linda around and talk to her
14:29hi linda it's hammer we need you to keep those eyes open lovely okay yeah okay that's fine well done and
14:39who's your surgeon can you remember broad beds pretty close
14:43as a speech therapist my involvement is to assess linda's speech and language throughout the
14:49operation so when she's awake we put her through a series of different tests i'm going to start
14:54stimulating and see if that affects your talking okay okay this allows the surgeon to to know what
15:00areas are potentially safe to take and for the surgeon to be able to recept as much tumor as possible
15:06are you with any pain linda no no no pain i mean discomfort let's do it discomfort ultimately the
15:14the patient is in control of this operation so if they're in any pain or discomfort we can adjust
15:19anything that we need to to help them try and open those eyes again linda because remember i need
15:24to get you to get you to look at pictures sorry it's okay i know it's hard back in the operating
15:38theater cutting edge robotic surgery is about to begin on 64 year old bruce who fractured his spine
15:45after a fall the fifth bone is just shattered a ct scan reveals that his pre-existing spinal
15:53abnormality will make for complex surgery yeah we can adapt and overcome like the sas just a lot
16:01slower and less macho we've all had a look at it we think we're going to try and include the fracture
16:08in in this construct so we'll just have to see how it translates on the patient mr carlton bland and
16:15mr stovall will use the surgical robot to fix seven screws into the spine
16:23and two in the pelvis they will be linked together with rods to form a scaffold to support bruce's
16:30body weight and allow the fracture to heal keep it coming south the robot maneuvers into place
16:42positioning itself at the exact location the screws will enter
16:48yeah that's looking good yeah right come over the robot knife then please
16:56knife to skim
16:57we're just cutting just exactly the width we need in order to place this screw
17:15so we're feeling for the bone
17:17the computer tells me i should be on the bone i am on the bone i can feel so there's very good
17:22agreement between the stands where the robot thinks we are and where we are robotic navigation guides the
17:30spinal screws with millimeter precision we've got to avoid the nerves and drill the depth of the screw
17:37sensors track against 3d ct scans in real time giving the surgeons a live map as they operate
17:52this bone is very very osteoporotic demineralized and quite thin and actually putting in these screws
17:58could potentially lead to further fractures and so we're going to be nice and careful with our technique
18:09you can see when i'm turning the screw you can actually see that changing
18:13as i push on the patient such is the accuracy of the system
18:19huge trust is placed in the robot
18:21just to illustrate the issues with doing this surgery perhaps two or three millimeters away
18:27that's where all the nerves are all of the movements and sensation of bladder and bowel
18:30function right there is a huge blood vessel that takes all the blood to the legs and so we really
18:36want to avoid all that the use of the robot makes this surgery incredibly accurate why does the accuracy
18:44of the screws matter well we're trying to avoid hitting the nerves the spinal cord and the peripheral
18:49nerves the corda equina if we put a one of these anchoring screws into the nerves that could lead
18:54to pain to numbness to weakness one screw is secure eight more to go
19:14so this is the fracture level the tricky broken bone bit so um we don't know what we're going to
19:18capture really the fractured area is the most dangerous section to drill
19:28i can feel some bone there
19:33okay so i can just feel bone on the outside and then there's a sudden drop off and that's into the
19:36fracture and there's there's nothing really there it's just like
19:42so the the risks when it's not safe in terms of our assessments and our feel is that we could be putting
19:47that screw deep into a blood vessel or into a nerve and obviously that's absolutely not where we want to be
20:01the walton center in liverpool carries out thousands of brain and spine operations every year
20:18but for some patients a precise diagnosis only emerges once surgery begins
20:32consultant neurosurgeon mr subawali feels empty doesn't it
20:37is performing spinal surgery on 64 year old keith to uncover what condition is affecting his legs
20:47okay open the dura see what we've got
20:50the dura is the tough outer membrane encasing the spinal cord and its fluid
20:55just focus in a bit on the scope okay yeah that's better you want to open up
21:08a fine incision exposes the space beneath get a hook in there watch out come out with the knife
21:16so
21:24beneath the dura lies the arachnoid membrane which surrounds the brain and spinal cord
21:31this web thin layer holds the cerebrospinal fluid
21:36a natural cushion that protects and lightens the weight of the brain
21:40there okay that might be enough exposure so let's try and keep the arachnoid intact if we can
21:54we've opened the duro this bit this next layer is the arachnoid there is a small
22:00hole in it but the csf isn't leaking out so there's a blockage isn't there
22:05yeah csf cerebrospinal fluid must flow freely in the spinal cord
22:14it's vitally important to get the csf flowing as quickly as possible
22:19if there is a blockage it can cause build up of pressure within the spinal cord and affect the
22:23function below the level of the blockage and in some cases if that pressure is permitted to
22:29remain high for an extended period of time it could lead to paralysis
22:35this looks thicker than it should be so let's just suck in that corner there
22:46what's going on here looks massive under there doesn't it
22:54the membrane looks swollen something beneath is distorting the space
23:01what the hell is this
23:05the
23:20professor broadbelt is in the midst of carrying out an awake craniotomy on 62 year old linda
23:26try and open those eyes again linda because remember i need to get you to look at pictures
23:29sorry it's okay it's okay he's removing a tumor that sits just millimeters from her speech center
23:40okay should we have a little go and just see linda is fully conscious throughout
23:45this is a lobster good this is a padlock well done this is a glove this is a monkey
23:54but before he can cut into her brain he must map out the size and exact location of the tumor
24:00this is a spider what you find is is as you start to get close to the bits of brain that are important
24:09for you talking or understanding speech this is a um tiger no what we see with linda is she starts to
24:17make errors she starts to struggle with finding the right word for things and that tells me hold on i'm
24:24starting to get a bit close did you stimulate them that was straight away i think this is her speech
24:31isn't it so the tumor's all under here when i stimulate that she stops being able to talk so
24:41we're going to stay away from that bit professor broadbelt has mapped the tumor's edge marking the boundary
24:50between cancer and the adjacent speech center right knife please
24:59it's knife to tumor she washed her face
25:04specialist speech and language therapist give me your sweet hannah jones reynolds must keep linda
25:14talking you sleep in a bed every word means her speech is safe blue is a color so hannah i'm going to be um
25:26getting closer now keep you talking daily he cooks the dinner oh i wish
25:31oh are you the main cook then are you linda yeah yeah um daily uh the little boy sits under a desk
25:40you're doing very well and we're on the um this i'm most worried about
25:45daily he fences well done professor broadbelt is cutting right at the edge of the speech center
25:52straight micro scissors every millimeter matters
25:55daily heat uh uh a person uh struggled a bit there i'm worried my worry is is that all of that is
26:09going to be speech linda's tumor is large removing it is as vital as it is dangerous this is a um
26:19uh a spinning wheel yeah hesitation again
26:35that's the arachnoid there
26:39mr sabawali has reached a critical point in keith's spinal surgery
26:43this is all abnormal he's just found an abnormality on the spine which should reveal the condition that
26:51is causing his walking to deteriorate i mean that might just be a cyst
27:01yeah assist so it looks like the problem that the patient has experienced is because of
27:07a cyst where the arachnoid should have been there's this thicker membrane which is the lining of a
27:15cyst spinal arachnoid cysts are rare accounting for only one to two percent of all lesions on the spine
27:25so it's got a membrane which is this tissue here and then fluid just accumulates within it
27:31so what we'll do is we'll try and remove as much of the lining of the cyst as we can focus
27:44to give keith the best chance of regaining sensation in his legs
27:48the blockage must be removed to restore the flow of cerebrospinal fluid just cut it out
27:57all that is not normal all that
28:01the cyst is stuck to the spinal cord so you've got to be very careful
28:07to mobilize the cyst wall try and remove as much of it as possible the cyst wall can send microscopic
28:14tendrils into the cord but chasing every last cell risks damaging the spinal cord
28:22it's a root isn't it it's stuck to a root
28:27see there's a balance in terms of trying to get as much of it away
28:30without risking damaging the spinal cord in the process
28:35it's almost like they're one it's not two distinct layers anymore
28:40i mean you can get it all off but at what cost
28:46i think you've got csf flow there
28:47so that's looking a bit more normal now agree all right
29:02now we have to try and put him back together blunt hook please
29:23never know what you're going to get with these particular cases best case scenario after an
29:28operation like this is that i would hope that he would notice some change in the sensation in
29:33his legs in a positive way
29:36the operation appears to have gone well but for keith
29:40the real test will come in recovery
29:59morning good morning
30:01how are you oh not so bad thank you so operation went really well that's good we found a cyst inside
30:08your spinal cord um but we managed to get most of the lining of it away so chances of it recurring
30:15is very small but not impossible um but i would expect that you would get immediate benefit really
30:21from us having done i can actually get feeling in the foot because one of the nurses walked past
30:26last night and touched him i could feel it
30:28that's good so immediately already finding some benefit in terms of improvement in your symptoms
30:34so that's really good all right thank you doctor thank you very much all right
30:41with rehabilitation and time the outlook for keith is bright
30:45the feelings come back a lot faster than i thought just gotta get up now and uh be physio and get
30:53about a bit let me take more holidays can't wait
31:05back in the trauma theater mr carlton bland and mr stovall are using a cutting edge robot
31:18to fix bruce's broken spine plan a is still on the tricky broken bone bit they've reached the most
31:27critical stage of the surgery attaching screws to the fractured part of the spine
31:33so we're not sure how much of a bike we're going to get at the fracture i'm going to just put the
31:39short screw in there bruce has a condition called ankylosing spondylitis let's try that
31:49causing his spine to fuse leaving it rigid and porous
31:56start to lose a bit of grip the screws could slip or snap
32:03that's as far as we're going to be able to go on that everything felt not bony everything felt
32:10quite soft so there was probably some blood clot there and we may have well been feeling some of
32:15the muscle or even potentially some of the anterior structures so we took that decision that we would
32:19compromise the hold a little bit but you know reduce the risk of us actually hitting a vital structure
32:25on one side the short screw has failed to grip we're trying the other side now
32:36everything now rests on the second side holding firm
32:39so we're having some sort of real purchase of the screw in the bone
32:50get some resistance that's a really good sign from my point of view because that means we've got really
32:55good hold of the patient and that'll be really useful in terms of this guy healing because if the
33:01brain fragments move they don't heal very well so i hold them nice and still really good
33:15now the final stage
33:19inserting the biggest screws deep into the pelvis
33:22with this condition we need to get some very good grip so these are huge screws we're going to put
33:30into his pelvic bone to be the foundations of this metalwork the stakes are higher here
33:40the pelvic screw is something i haven't done before with a robot
33:44for our pelvic organs to be thinking about uh and so the bowel and the bladder become more more of a
33:50concern there's a bit of resistance i think i need to go a little bit deeper but i'm not sure if i'm
33:57on the other side that's the only thing i should just well we will find out
34:20right next to it straight like scissors this is a record player excellent this is a refrigerator
34:32at the walton center surgeons carry out some of the most complex brain operations in the country
34:38give me your sweets among them are awake craniotomies this is a hat performed only a few dozen times each
34:47year this is a post with this technique as much of a tumor as possible is removed from delicate areas
34:55of the brain while preserving vital functions
35:00trying to work my way around this tumor we're getting pretty close to it professor broadbelt is
35:07operating on 62 year old linda this is a a rhinoceros hesitation now yeah he's cutting just millimeters from the
35:19area that controls speech this is a spider this is a um a spinning wheel yeah hesitation again okay this is a
35:30uh um and again twice in a row so we're obviously pretty close you're doing amazing linda scissors
35:38micro please this is a spoon yeah this is a squirrel good he's carefully separating tumor from healthy brain
35:48this is a um uh oh struggling there are you doing fantastic you can keep going a little bit longer that
35:58would be really helpful this is a sofa this is a chair good this is a a centipede um caterpillar struggle
36:09then okay i'm going to give you a big chunk of tumor very very shortly four steps please
36:15so there's a good chunk of our tumor the tumor will be sent for analysis to guide further treatment
36:30and everything okay hannah there yeah she's speaking really well really well so i'm just gonna have a
36:36little look around the area that affected you so if you just keep talking okay this is a bed this is a
36:48fly this is a bear that looks all right you know this is a bell this is a belt so i think i've probably
36:56done as much as i need to do it looks like i'm pretty much to healthy brains and she's still talking which
37:02is all good this is a carrot you can relax again now i think we're done oh fantastic how good you've
37:10done absolutely incredibly linda well done are you happy yes i'm happy yeah happy it's over happy it's over
37:17exactly the tumor is out and linda's speech is intact
37:23so there's the hole speech area there and the brain looks healthy underneath so right time to close
37:39i think it went well um it was useful having her awake um if i was a little bit too generous with where
37:45i was going um it stopped her speaking so we just came back and was able to get everything that looked
37:51abnormal out so that's good three days after her surgery linda is up and about
38:09great news going home
38:13i can't actually believe that somebody's been operating in my brain and that i've come out
38:17speaking like i am voice sounds exactly the same as it normally does really good
38:24i'm going home it's actually you know when it suddenly feels i yeah i actually felt butterflies
38:29and excitement yes just like hit me a bit yeah i'm actually it's actually happening
38:41in the trauma theater robotic spinal surgery on 64-year-old bruce has reached a crucial moment
38:52but i'm not sure if i'm at the other side that's the only thing i just don't want to go too far
38:56the robot is used to place the final anchor screws into the pelvis
39:00mr carlton bland and mr stovall have spent the past three hours working in tandem should go down
39:11that hole that we made helvik screws 10 centimeters long and a centimeter wide huge bits of metalwork
39:19transfer his body weight from the good bone above the fracture down through to the good bone below the
39:25fracture essentially taking the weight so it doesn't move as much and so it can heal together
39:33now the brute force phase securing the screw to the pelvis
39:41so there's so much force required i'm actually having to hold the pelvis
39:44underneath the patient because he keeps on rolling away from the screw
39:46progress is slow the screw must cut a path through dense pelvic bone without drifting off course it's
39:56the most dangerous part of the operation there are pelvic organs that we don't want to hit
40:03power versus precision push too hard and they risk damaging organs too soft and the screw won't hold
40:12go on that
40:18that's fine i think so one anchor in but he needs two we're on the last screw now the second screw
40:26falls to mr colton bland the tough part
40:31yeah lovely lovely lovely lovely that's looking good that's what we want let's cross the joint yeah that's fine
40:46okay x-ray there please
40:58the moment of truth an x-ray will show if the scaffold lines up to bridge the fracture
41:04great okay that's great thank you
41:17good news uh the robot has helped us put these screws into exactly where we wanted to be
41:23uh so that's really reassuring and so now we're going to link all of these anchor points these screws
41:28together to pass the body weight through bypassing the fracture
41:34so mr carlton bland threads titanium rods through the holes in the screws to form a rigid scaffold to
41:43support the spine
41:51with the construct secure the guides can be removed and the incisions closed
41:56you can look at this broken bone and put in some metal work and the x-rays look great but you don't
42:04know how the patient's going to respond and so um we do the operation we close up and we kind of
42:10twiddle our thumbs and we wait and it's an anxiety provoking time it's like waiting for exam results
42:24after an anxious 24-hour wait bruce is recovering on the ward
42:43whoa hi bruce how are you all right thanks mate good yeah how are things feeling i'm feeling pretty
42:48good really pain free at the moment good so hopefully that fracture is a bit more stable
42:55um in terms of your legs you can give him a good wiggle excellent good stuff good stuff thank you
43:01very much no that's quite all right that's what we're doing cheers then right i will see you again
43:05okay thank you very much thank you
43:10he's a lot more comfortable than he was before the operation he could hardly
43:14move or roll so uh i think that's a really really good result he's got no nerve problems which is
43:19great uh and so we'll begin the process of building him back up and mobilizing him and
43:24getting him up and on his feet i've always wanted to do a parachute jump
43:31you know um well who knows really to me right now at this moment the world's my oyster
43:38and it's down to the the staff everybody who's been involved i can't thank them all enough it's been
43:58so
44:05so
44:10so
44:12so
44:22Transcription by CastingWords
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