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00:00in the heart of liverpool okay let's go is an operating theater like no other
00:09doctors are the pinnacle of their profession ah big nest of vipers that's all totally abnormal
00:20fight to save lives are you all right buddy a bit of pain there yeah straight down my face
00:27in neurosurgeon being able to change lives better there's no other job that i'd rather be doing
00:32it's high stakes surgery this is amazing i've not seen anything like this before
00:39ready steady go if you cause an injury to the brain or the spinal cord you can't repair it
00:44that's it forever using groundbreaking technology making life or death decisions
00:51oh yes a sea of blood if we don't do anything we should die he needs to wake up i think it's
01:00gone well it feels really good i love it when a pond comes together this is trauma room one
01:07it's 8 a.m the walton center in liverpool a patient is inbound
01:2364 year old bruce has a broken back
01:32still a bit vague i mean so i go into the kitchen got the cup ready and put the kettle on and then
01:43i just passed out i can't remember much more after that then i woke up but i tried to move
01:50and uh it was just so bad the pain i thought i've done something to myself here
01:56i mean so much pain it is really bad
02:00surgeons at the walton center treat around 170 people with broken backs every year
02:09operating on bruce is consultant neurosurgeon mr nick carlton bland
02:15bruce has a pre-existing medical condition this is a strange uh condition called ankylosing
02:27spondylitis this is his ct scan it's almost like the spine has all started to merge together like a
02:34like a melting candle almost the bones are fusing together but also they're quite quite thin
02:40now the issues with this is that if you were to suffer a fall or an injury which he has um it can
02:47lead to a fracture of those fused bones and what we're interested in is this bone down here
02:52he's broken the bone there so what we're going to do today very simply is essentially to put in
02:58some scaffolding around the spine and stabilize his back
03:01it's a complex procedure one that calls for a piece of cutting edge kit
03:09we're very lucky here at liverpool's walton center that we have a state-of-the-art surgical robot
03:19literally designed for this purpose before the robot spinal surgery would involve doing a very long
03:27incision stripping off the muscles there's going to be a lot of blood loss associated with that
03:30and what the robot allows us to do is to scan the patient with a ct scan to reconstruct that data
03:36in the robot and then we can just make very small skin incisions to sneak in and therefore we don't
03:43lose the blood that we would see in open surgery
03:46but before surgery can begin there's a challenge
03:53so there are some issues that we encounter with this condition one is the shape of the patient the
03:58patient's very very hunched over and this gives us airway problems and the positioning problems
04:02so actually putting him onto a table is going to be a difficulty for us and so we're going to
04:07be positioning very carefully to support his shape so there are some real technical challenges
04:12just to get the patient onto the table asleep
04:14the operation requires two surgeons that's the risk isn't it you don't want to break his neck on
04:22positioning him working alongside mr. colton bland is consultant neurosurgeon mr. matthew stovell
04:29make sure his body's good his head's good and and then when we're happy with that yeah then we bed in
04:35doubt there are stories of patients with ankylosing spondylitis with this very marked curve actually
04:41sustaining a fracture during positioning okay it takes the whole team to move bruce with absolute
04:50precision even the smallest shift could damage his brittle spine even more
04:56ready steady slide okay and when we roll him we're gonna go real slow real gentle okay yeah
05:04one two three okay that's good good good yeah great thank you i'm happy with how it's going
05:20i mean luckily the setup we've got here has been able to accommodate this curvature and actually
05:24we've got quite a nice position so i'm pleased with that so far so good
05:33with bruce secure reference markers are fixed to guide the robot
05:40that does feel quite strong actually let's go with that
05:42a ct scan maps the spine
05:54that's really rubbish isn't it around the fracture i think it's mood is open a bit yeah
05:59but it reveals a problem there's a fracture line there so you will actually cross a fracture line
06:04what we're seeing here on the ct scan the fracture actually just by positioning him has opened right up
06:09and that gives us a surgical problem because we have to decide how we can capture that broken bone
06:16which obviously is moving around so we're just seeing if it's technically possible we'd have to
06:20check the angles of all the screws that we're planning there yeah
06:30the walton center in liverpool is one of the country's leading specialist hospitals for neurology and neurosurgery
06:49here teams take on the most complex and sometimes the most mysterious conditions
06:54it is not uncommon to find patients that are a mystery many people would expect that an mri scan
07:05for example would give you a diagnosis sometimes the mri scan just tells us that there's something there
07:11that shouldn't be there and we don't know exactly what we're going to find until we go inside and explore
07:1764 year old keith has unexplained symptoms that have steadily been getting worse
07:27looks like i walk on wooden stilts because i just can't bend my legs the muscles that tight
07:32but they go hot or very cold and they just i just walk along and sometimes i might trip
07:40i've done physio pilates even had a massage on them she's pressing on the back of me
07:46the calf muscle quite strongly and i said are you tickling me with a feather they said no she's
07:52pressing pressing really hard
08:01are we ready to rock and roll tasked with trying to diagnose and fix keith
08:07is consultant neurosurgeon mr sean subawali
08:11most surgeons are control freaks we like to have as much control over the situation as we can we
08:17like to plan as far ahead as we can so that we don't have surprises in this case we're going to
08:24have a surprise because we don't know what it is that's causing the problem
08:32it seems to be an issue in keith's spinal cord the area that transmits nerve signals to his legs
08:38now if you look at the mri scan here is the spinal cord this black structure here
08:45either side of the spinal cord you've got the spinal fluid now as you follow the spinal cord down you can
08:51see that it's moving more and more forward in terms of its position and inside the spinal cord you can
08:57see this white area here there's an abnormality there some sort of mass hiding within that fluid space
09:05so we can see the effect of it but we can't see what it is so we'll find out once we open him up
09:18the first cut exposes the back of keith's thoracic spine the middle part of the backbone
09:25so the first thing that we need to do is to dissect the muscle you see
09:30put some retractors in which keeps everything open so we've got a corridor that we can work down
09:40do we have the bone scalpel
09:46to reach the spinal cord mr subawali will carry out a laminectomy removing a section of bone in the
09:51vertebrae we can remove the bone
10:04okay get the microscope in
10:08and we'll be able to see the spinal cord
10:12okay so now we have our jewellery so that's the outside
10:17tough lining of the spinal cord what's going on here zoom in a bit please
10:30a close-up of the dura reveals an abnormality
10:36feels empty doesn't it the fluid space beneath has collapsed
10:42that's not normal to reach the problem mr subawali must cut deeper it's a very dangerous operation
10:52to perform you're very close to the spinal cord the slightest slip of the hand could paralyze the patient
11:08the walton center in liverpool treats around 450 brain tumor patients every year
11:24one of them is 62 year old linda
11:28i was noticing that my speech wasn't as
11:33that this pattern of speech was a bit strange i went to the gp and he sent me for emergency ct scan
11:40said
11:43you have you have something in your head
11:46okay
11:56hi linda my name's jess i'll be looking after you in here okay today professor andrew broadbelt will
12:01carry out a craniotomy to remove the tumor but to do so he will wake linda up during the surgery
12:08okay okay linda hope those all well thanks very much with linda her tumor is near her speech area
12:17and certainly we know that if you are aggressive with these tumors that patients can lose the
12:25ability to speak afterwards that can be for a short period of time or permanently and one way of trying
12:31to reduce that risk is we wake them up take as much down as possible whilst preserving the speech
12:42if we look at her scans so this is her as if we cut the top of her head off and this white thing
12:47is a tumor we think this is an aggressive type of brain cancer something called aglioblastoma
12:54and if we can take everything out that looks abnormal on the scan all that white stuff
13:00then she'll do better with treatment aglioblastoma is the fastest growing brain tumor
13:10we good yeah we okay to start yeah
13:16self-retaining retractor please linda's operation is urgent thank you forceps please
13:30the tumor's all under that this is the bit i'm worried about speech around here drill please
13:43next step remove the skull and we use like a little jigsaw to make a hole in the bone
13:50to create an access window leading to the brain
13:53so there's our bone a little bit of bone there you go this is the area i'm worried about our speech
14:08area is all here tumors all in there and i really want to go in here to get into it but it'll depend
14:17if this is speech then i'll have to come further forward further higher up and find somewhere that's safe
14:23the tumor sits just millimeters from the function that controls speech
14:30to avoid damaging it the team will now bring linda around and talk to her
14:37hi linda it's hammer we need you to keep those eyes open lovely okay yeah okay that's fine well done
14:44and who's your surgeon can you remember broad beds pretty close
14:48as a speech therapist my involvement is to assess linda's speech and language throughout the operation
14:55so when she's awake we put her through a series of different tests i'm going to start stimulating
15:00and see if that affects your talking okay okay this allows the surgeon to to know what areas are
15:06potentially safe to take and for the surgeon to be able to recept as much tumor as possible
15:11are you with any pain linda no no no pain i mean discomfort let's do it a discomfort ultimately
15:19the the patient is in control of this operation so if they're in any pain or discomfort we can adjust
15:24anything that we need to to help them try and open those eyes again linda because remember i need to
15:29get you to get you to look at pictures sorry it's okay i know it's hard
15:42back in the operating theater cutting edge robotic surgery is about to begin on 64 year old bruce
15:49who fractured his spine after a fall
15:51the fifth bone is just shattered a ct scan reveals that his pre-existing spinal abnormality will make
16:00for complex surgery yeah we can adapt and overcome like the sas just a lot slower and less macho
16:09we've all had a look at it we think we're going to try and include the fracture in in this construct
16:14so we'll just have to see how it translates on the patient
16:16mr carlton bland and mr stovell will use the surgical robot to fix seven screws into the spine
16:28and two in the pelvis they will be linked together with rods to form a scaffold
16:34to support bruce's body weight and allow the fracture to heal
16:38keep it coming south the robot maneuvers into place positioning itself at the exact location the screws
16:50will enter yeah that's looking good yeah right come over the uh robot knife then please
16:57knife to skim
17:08we're just cutting just exactly the width we need in order to place this screw
17:20so we're feeling for the bone
17:22the computer tells me i should be on the bone i am on the bone i can feel so there's very good
17:27agreement between the scans where the robot thinks we are and where we are robotic navigation guides the
17:35spinal screws with millimeter precision we've got to avoid the nerves and drill the depth of the screw
17:42sensors track against 3d ct scans in real time giving the surgeons a live map as they operate
17:57this bone is very very osteoporotic demineralized and quite thin and actually putting in these screws
18:03could potentially lead to further fractures and so we're going to be nice and careful with our technique
18:12you can see when i'm turning the screw you can actually see that changing as i push on the
18:19patient such is the accuracy of the system huge trust is placed in the robot
18:28just to illustrate the issues with doing this surgery perhaps two or three millimeters away
18:32that's where all the nerves are all of the movements and sensation and bladder and bowel
18:35function right there is a huge blood vessel that takes all the blood to the legs
18:40and so we really want to avoid all that the use of the roadblock makes this surgery incredibly
18:47accurate why does the accuracy of the screws matter well we're trying to avoid hitting the nerves the
18:52spinal cord and the peripheral nerves the corda equina if we put a one of these anchoring screws
18:58into the nerves that could lead to pain to numbness to weakness one screw is secure eight more to go
19:09so this is the fracture level the tricky broken bone bit so um we don't know what we're going to capture really
19:24the fractured area is the most dangerous section to drill
19:32i can feel some bone there
19:38okay so i can just feel bone on the outside and then there's a sudden drop off and that's into the
19:41fracture and there's there's nothing really there it's just like
19:44so the the risks when it's not safe in terms of our assessments and our feel is that we could be
19:52putting that screw deep into a blood vessel or into a nerve and obviously that's absolutely not where we
19:57want to be
20:11the walton center in liverpool carries out thousands of brain and spine operations every year
20:26but for some patients a precise diagnosis only emerges once surgery begins
20:31consultant neurosurgeon mr subawali feels empty doesn't it is performing spinal surgery on 64 year old keith
20:47to uncover what condition is affecting his legs
20:50okay open the dura see what we've got the dura is the tough outer membrane encasing the spinal cord and its fluid
21:02just 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
21:29beneath the dura lies the arachnoid membrane which surrounds the brain and spinal cord
21:34this web thin layer holds the cerebrospinal fluid
21:41a natural cushion that protects and lightens the weight of the brain
21:50there okay that might be enough exposure so let's try and keep the arachnoid intact if we can
21:58we've opened the dura this bit
22:00this next layer is the arachnoid there is a small hole in it but the csf isn't leaking out
22:08so there's a blockage isn't there
22:12csf cerebrospinal fluid must flow freely in the spinal cord
22:19it's vitally important to get the csf flowing as quickly as possible
22:24if there is a blockage it can cause buildup of pressure within the spinal cord and affect the function
22:29below the level of the blockage and in some cases if that pressure is permitted to
22:34remain high for an extended period of time it could lead to paralysis
22:41this looks thicker than it should be so let's just suck in that corner there
22:49what's going on here looks massive under there doesn't it
22:59the membrane looks swollen something beneath is distorting the space
23:06what the hell is this
23:19the
23:25professor broadbelt is in the midst of carrying out an awake craniotomy on 62 year old linda
23:31try and open those eyes again linda because remember i need to get you to look at pictures
23:34sorry it's okay it's okay he's removing a tumor that sits just millimeters from her speech center
23:41okay should we have a little girl and just see linda is fully conscious throughout
23:51this is a lobster good this is a padlock well done this is a glove this is a monkey
23:58but before he can cut into her brain he must map out the size and exact location of the tumor
24:07this is a spider good what you find is is as you start to get close to the bits of brain that are
24:14important for you talking or understanding speech this is a um tiger now what we see with linda is she
24:22starts to make errors she starts to struggle with finding the right word for things and that tells
24:28me hold on i'm starting to get a bit close did you stimulate them that was straight away
24:35i think this is a speech isn't it
24:37so the tumor's all under here when i stimulate that she stops being able to talk so we're going to
24:46stay away from that bit professor broadbelt has mapped the tumor's edge marking the boundary between
24:55cancer and the adjacent speech center all right knife please
24:59it's knife to tumor she washed her face
25:12specialist speech and language therapist give me your sweets hannah jones reynolds must keep linda
25:19talking you sleep in a bed every word means her speech is safe blue is a color
25:27so hannah i'm going to be um getting closer now keep you talking daily he cooks the dinner oh i wish
25:38are you the main cook then are you linda yeah yeah um daily uh the little boy sits under a desk
25:45you're doing very well and we're on the um this i'm most worried about
25:50daily he fences well done professor broadbelt is cutting right at the edge of the speech center
25:57straight micro scissors every millimeter matters
26:03daily heat uh the starch is a uh a person uh struggled a bit there i'm worried my worry is is that
26:13all of that is going to be speech linda's tumor is large removing it is as vital as it is dangerous
26:22this is a um a spinning wheel yeah hesitation again
26:40that's the arachnoid there mr subawali has reached a critical point in keith's spinal surgery
26:48this is all abnormal he's just found an abnormality on the spine which should reveal the condition that
26:56is causing his walking to deteriorate i mean that might just be a cyst
27:01so it looks like the problem that the patient has experienced is because of a cyst
27:14where the arachnoid should have been there's this thicker membrane which is the lining of a cyst
27:21spinal arachnoid cysts are rare accounting for only one to two percent of all lesions on the spine
27:30so it's got a membrane which is this tissue here and then fluid just accumulates within it
27:36so what we'll do is we'll try and remove as much of the lining of the cyst as we can focus
27:43to give keith the best chance of regaining sensation in his legs
27:53the blockage must be removed to restore the flow of cerebrospinal fluid just cut it out
28:02all that is not normal all that
28:04the cyst is stuck to the spinal cord so you've got to be very careful
28:12to mobilize the cyst wall try and remove as much of it as possible
28:17the cyst wall can send microscopic tendrils into the cord but chasing every last cell risks damaging
28:25the spinal cord it's a root isn't it it's stuck to a root
28:29so there's a balance in terms of trying to get as much of it away without risking damaging the
28:37spinal cord in the process it's almost like they're one it's not two distinct layers anymore
28:45i mean you can get it all off but at what cost
28:51i think you've got csf flow there restoring the flow of csf is vital to keep the nervous system
28:58functioning when we opened up there was no flow of csf because the cyst was in the way
29:04so once the cyst has been removed now we can see the spinal fluid can flow above and below where the
29:09blockage was so that's looking a bit more normal now agree all right
29:17now we have to try and put him back together blunt hook please
29:28never know what you're going to get with these particular cases
29:31best case scenario after an operation like this is that i would hope that he would notice some
29:36change in the sensation in his legs in a positive way
29:39the operation appears to have gone well but for keith the real test will come in recovery
29:56so
30:04morning good morning how are you oh not so bad thank you so operation went really well that's good
30:11we found a cyst inside your spinal cord um but we managed to get most of the lining of it away
30:19so chances of it recurring is very small but not impossible
30:22right um but i would expect that you would get immediate benefit really from us having done
30:27i have i can actually get feeling in my foot because one of the nurses walked past last night
30:31and touched him i could feel it that's good so immediately already finding some benefit in terms
30:37of improvement in your symptoms so that's really good all right thank you doctor thank you very much all
30:43all right with rehabilitation and time the outlook for keith is bright the feelings come back a lot faster
30:54than i thought just got to get up now and uh be physio and get up out a bit they take more holidays can't wait
31:13so
31:17back in the trauma theater mr carlton bland and mr stovall are using a cutting-edge robot to fix bruce's
31:24broken spine plan a is still on the tricky broken bone bit they've reached the most critical stage of
31:32the surgery
31:35attaching screws to the fractured part of the spine
31:38so we're not sure how much of a bites we're going to get at the fracture i'm going to just put the short
31:45screw in there
31:48bruce has a condition called ankylosing spondylitis
31:52let's try that causing his spine to fuse leaving it rigid and porous
31:58start to lose a bit of grip the screws could slip or snap yeah that's as far as we're going to be able
32:09to go on that everything felt not bony everything felt quite soft so there was probably some blood
32:17clot there and we may have well been feeling some of the muscle or even potentially some of the anterior
32:22structures so we took that decision that we would compromise the hold a little bit but you know
32:27reduce the risk of us actually hitting a vital structure
32:33on one side the short screw has failed to grip we're trying the other side now
32:41everything now rests on the second side holding firm
32:44so we're having some sort of real purchase of the screw in the bone
32:54getting some resistance
32:57that's a really good sign from my point of view because that means we've got really good hold
33:00of the patient and that'll be really useful in terms of this guy healing because if the bone
33:06fragments move they don't heal very well so i'll hold them nice and still really good
33:14now the final stage
33:24inserting the biggest screws deep into the pelvis
33:30with this condition we need to get some very good grip so these are huge screws we're going to put
33:35into his pelvic bone to be the foundations of this metalwork the stakes are higher here
33:44the pelvic screw is something i haven't done before with a robot
33:49there are pelvic organs to be thinking about and so the bowel and the bladder become more more of a concern
33:58there's a bit of resistance i think i need to go a little bit deeper
34:01but i'm not sure if i'm outside that's the only thing i should just well we will find out
34:14we're right next to it straight like scissors please this is a record player excellent this is a refrigerator
34:34at the walton center surgeons carry out some of the most complex brain operations in the country
34:43give me your sweet among them are awake craniotomies this is a hat performed only a few dozen times each
34:52year this is a horse with this technique as much of a tumor as possible is removed from delicate areas
35:00of the brain while preserving vital functions
35:05trying to work my way around this tumor we're getting pretty close to it professor broadbelt is
35:12operating on 62 year old linda this is a a rhinoceros hesitation now yeah he's cutting just millimeters from the
35:24area that controls speech this is a spider this is a um a spinning wheel yeah hesitation again okay this is a
35:35uh um and again twice in a row so we're obviously pretty close you're doing amazing linda scissors
35:43microphones this is a spoon yeah this is a squirrel good he's carefully separating tumor from healthy brain
35:53this is a um oh struggling there are you doing fantastic you can keep going a little bit longer that'd be really
36:03help now this is a sofa this is a chair good this is a a centipede um caterpillar struggle then
36:15okay i'm going to give you a big chunk of tumor very very shortly forceps please
36:27so there's a good chunk of our tumor
36:28the tumor will be sent for analysis to guide further treatment
36:35and everything okay hannah there yeah she's speaking really well really well so i'm just
36:40gonna have a little look around the area that affected you so if you just keep talking okay
36:50this is a bed this is a fly this is a bear oh it's all right you know this is a bell
36:59this is a belt so i think i've probably done as much as i need to do it looks like i'm pretty
37:04much to healthy brains and she's still talking which is all good this is a carrot you can relax again
37:10now i think we're done oh fantastic how good you've done absolutely incredibly linda well done
37:18are you happy yes i'm happy yeah happy it's over happy it's over exactly
37:25the tumor is out and linda's speech is intact
37:28so there's the hole speech area there and the brain looks healthy underneath so right time to close
37:41i think it went well um it was useful having her awake um if i was a little bit too generous with
37:49where i was going um it stopped her speaking so we just came back um and was able to get everything
37:56they looked abnormal out so that's good three days after her surgery linda is up and about
38:14great news going home
38:15i can't actually believe that somebody's been operating in my brain and that i've come out
38:22speaking like i am voice sounds exactly the same as it normally does really good
38:29i'm going home it's actually you know when it suddenly feels oh yeah i actually felt butterflies
38:33and excitement yes just like hit me a bit yeah actually it's actually happening
38:50in the trauma theater robotic spinal surgery on 64-year-old bruce has reached a crucial moment
38:57but i'm not sure if i'm out the other side that's the only thing i just don't want to go too far
39:01the robot is used to place the final anchor screws into the pelvis doing well matt
39:09mr carlton bland and mr stovall have spent the past three hours working in tandem should go down
39:16that hole that we made helvik screws 10 centimeters long and a centimeter wide huge bits of metalwork
39:24transfer his body weight from the good bone above the fracture down through to the good bone below
39:30the fracture essentially taking the weight so it doesn't move as much and so it can heal together
39:38now the brute force phase securing the screw to the pelvis
39:46so there's so much force required i'm actually having to hold the pelvis
39:48from underneath the patient because he keeps on rolling away from the screw
39:51progress is slow the screw must cut a path through dense pelvic bone without drifting off course it's
40:01the most dangerous part of the operation there are pelvic organs that we don't want to hit
40:08power versus precision push too hard and they risk damaging organs too soft and the screw won't hold
40:17go on that
40:23that's fine i think so one anchor in but he needs two we're on the last screw now the second screw
40:31falls to mr carlton bland the tough part
40:40yeah lovely lovely lovely lovely that's looking good that's what we want
40:49let's cross the joint yeah that's fine
40:51okay x-ray there please
41:03the moment of truth an x-ray will show if the scaffold lines up to bridge the fracture
41:09great okay that's great thank you good news uh the robot has helped us put these trees into
41:26exactly where we wanted to be so that's really reassuring and so now we're going to link all of
41:31these anchor points these screws together to pass the body weight through bypassing the fracture
41:41mr carlton bland threads titanium rods through the holes in the screws to form a rigid scaffold to
41:48support the spine
41:49with the construct secure the guides can be removed and the incisions closed
42:05you can look at this broken bone and put in some metal work and the x-rays look great
42:09but you don't know how the patient's going to respond and so um we do the operation we close up and we kind
42:14of twiddle our thumbs and we wait and it's an anxiety provoking time it's like waiting for exam results
42:37after an anxious 24-hour wait bruce is recovering on the ward
42:44so
42:47whoa hi bruce how are you all right thanks mate good yeah how are things feeling i'm feeling pretty
42:53good really paying free at the moment good so hopefully that fracture is a bit more stable
42:59um in terms of your legs you can give him a good wiggle excellent good stuff good stuff thank you
43:06very much no that's quite all right that's what we do cheers then right and we'll see you again okay
43:11thank you very much thank you he's a lot more comfortable than he was before the operation he
43:18could hardly move or roll so uh i think that's a really really good result he's got no nerve problems
43:24which is great uh and so we'll begin the process of building him back up and mobilizing him and
43:29getting him up and on his feet i've always wanted to do a parachute jump you know um but who knows we
43:40to me right now at this moment the world's my oyster and it's down to the the staff everybody
43:46who's been involved i can't thank them all enough it's been brilliant
44:04so
44:16so
44:30so
44:36so
44:40Transcription by CastingWords
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