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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 yes take 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 going it's high stakes surgery this is amazing i've not seen anything like this before ready
00:34steady go if you cause an injury to the brain or the spinal cord you can't repair it that's
00:40it forever using groundbreaking technology making life or death decisions oh yes a sea of blood
00:50if we don't do anything she'd die he needs to wake up i think it's gone well it feels really good
00:57i love it when a pond comes together this is trauma room one
01:14it's 8 a.m the walton center in liverpool a patient is inbound
01:1864 year old bruce has a broken back
01:30still a bit vague i mean so i go into the kitchen got my cup ready and put the kettle on and then i just
01:38passed out i can't remember much more after that then i woke up but i tried to move and uh it was just so
01:48bad the pain i thought i've done something to myself here i mean so much pain it is really bad
01:59surgeons at the walton center treat around 170 people with broken backs every year
02:06operating on bruce is consultant neurosurgeon mr nick carlton bland
02:10bruce has a pre-existing medical condition this is a strange uh condition called ankylosing spondylitis
02:24this is his ct scan it's almost like the spine has all started to merge together like a like a melting
02:30candle almost the bones are fusing together but also they're quite quite thin
02:35now the issues with this is that if you were to suffer a fall or an injury which he has um it can
02:42lead to a fracture of those fused bones and what we're interested in is this bone down here
02:48he's broken the bone there so what we're going to do today very simply is essentially to put in
02:53some scaffolding around the spine and stabilize his back
02:56it'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
03:15literally designed for this purpose before the robot spinal surgery would involve doing a very long
03:22incision stripping off the muscles there's going to be a lot of blood loss associated with that
03:26and 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 the
03:53patient's very very hunched over this gives us airway problems and the positioning problems so
03:58actually 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 just to
04:07getting the patient onto the table asleep
04:12the operation requires two surgeons that's the risk isn't it you don't want to break his neck on
04:17positioning him working 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 need
04:30better than that there are stories of patients with ankylosing spondylitis with this very marked curve
04:36actually sustaining a fracture during positioning okay
04:40it takes the whole team to move bruce with absolute precision even the smallest shift could damage his
04:48brittle spine even more ready steady slide okay and when we roll him we're gonna go real slow real
04:57gentle okay yeah one two three okay that's good good good yeah great thank you i'm happy with how it's
05:15going i mean luckily 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
06:03has opened right up and that gives us a surgical problem because we have to decide
06:09how we can capture that broken bone which obviously is moving around so we're just seeing
06:13if it's technically possible we'd have to check the angles of all the screws that we're planning there
06:29the walton center in liverpool is one of the country's leading specialist hospitals for neurology
06:39and neurosurgery here teams take on the most complex and sometimes the most mysterious conditions
06:52it is not uncommon to find patients that are a mystery
06:57many people would expect that an mri scan for example would give you a diagnosis
07:03sometimes the mri scan just tells us that there's something there that shouldn't be there
07:08and we don't know exactly what we're going to find until we go inside and explore
07:1664 year old keith has unexplained symptoms that have steadily been getting worse
07:22looks like i walk on wooden stilts because i just can't bend my legs the muscles
07:26that type they go hot or very cold and i just i just walk along and sometimes i might trip
07:35i've done physio pilates even had a massage on them she's pressing on the back of me
07:41the calf muscle quite strongly and i said are you titling me with a feather
07:46i said no she's pressing pressing really hard
07:56are we ready to rock and roll tasked with trying to diagnose and fix keith is consultant neurosurgeon mr
08:04sean subawali most surgeons are control freaks we like to have as much control over the situation as
08:12we can we like to plan as far ahead as we can so that we don't have surprises in this case we're
08:19going to have a surprise because we don't know what it is that's causing the problem
08:27it seems to be an issue in keith's spinal cord the area that transmits nerve signals to his legs
08:33now if you look at the mri scan here is the spinal cord this black structure here either side of the
08:41spinal cord you've got the spinal fluid now as you follow the spinal cord down you can see that it's
08:46moving more and more forward in terms of its position and inside the spinal cord you can see
08:52this white area here there's an abnormality there some sort of mass hiding within that fluid space
09:01so we can see the effect of it but we can't see what it is so we'll find out once we open him off
09:13the first cut exposes the back of keith's thoracic spine the middle part of the backbone
09:20so the first thing that we need to do is to dissect the muscle you see
09:25put 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
09:41to reach the spinal cord mr subawali will carry out a laminectomy removing a section of bone in the
09:47vertebrae we can remove the bone
09:59okay get the microscope in and we'll be able to see the spinal cord
10:05okay so now we have our jura so that's the outside tough lining of the spinal cord
10:16what's going on here zoom in a bit please
10:20a close-up of the deora reveals an abnormality
10:31feels empty doesn't it
10:34the fluid space beneath has collapsed
10:36that's not normal to reach the problem mr subawali must cut deeper it's a very dangerous operation
10:47to 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
11:17one of them is 62 year old linda
11:23i was noticing that my speech wasn't as that this pattern of speech was a bit strange i went to
11:32the gp and he sent me for emergency ct scan said um you have you have something in your head
11:47um
11:53okay today professor andrew broadbelt will carry out a craniotomy to remove the tumor
12:00but to do so he will wake linda up during the surgery
12:03okay okay linda hope those all well for you thanks very much with linda her tumor
12:10is near her speech area and certainly we know that if you are aggressive with
12:17these tumors that patients can lose the ability to speak afterwards that can be
12:22for a short period of time or permanently and one way of trying to reduce that risk is we wake them up
12:29take as much out as possible whilst preserving her 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
12:43her 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 yeah
13:08self-retaining retractor please linda's operation is urgent thank you forceps please
13:25tumors 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 this 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
14:29okay we need you to keep those eyes open lovely okay yeah okay that's fine well done and who's your
14:39surgeon can you remember broad beds pretty close as a speech therapist my involvement is to assess
14:47linda's speech and language throughout the operation so when she's awake we put her through a series of
14:52different tests i'm going to start stimulating and see if that affects your talking okay okay this allows
14:59the surgeon to to know what areas are potentially safe to take and for the surgeon to be able to
15:04recept as much tumor as possible are you with any pain linda no no no pain i mean discomfort let's do
15:12a discomfort ultimately the the patient is in control of this operation so if they're in any pain or
15:17discomfort we can adjust anything that we need to to to help them try and open those eyes again linda
15:23because remember i need to get you to look at pictures sorry it's okay i know it's hard
15:37back in the operating theater cutting edge robotic surgery is about to begin
15:42on 64 year old bruce who fractured his spine after a fall
15:46the fifth bone is just shattered a ct scan reveals that his pre-existing spinal abnormality
15:54will make for complex surgery yeah we can adapt and overcome like the sas
16:01just a lot slower and less macho we've all had a look at it we think we're going to try and include
16:07the fracture in in this construct so we'll just have to see how it translates on the patient
16:12mr carlton bland and mr 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
16:29to support bruce's body weight and allow the fracture to heal
16:33keep it coming south the robot maneuvers into place positioning itself at the exact location the screws
16:45will enter yeah that's looking good yeah right come over the uh robot knife then please
16:52knife to skim
17:03we're just cutting just exactly the width we need in order to place this screw
17:15so we're feeling for the bone
17:19the computer tells me i should be on the bone i am on the bone i can feel
17:22so there's very good agreements between the stands where the robot thinks we are and where we are
17:28robotic navigation guides the spinal screws with millimeter precision
17:34we've got to avoid the nerves and drill the depth of the screw
17:40sensors 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
18:03you can see when i'm turning the screw you can actually see that changing as i push on the patient
18:15such is the accuracy of this 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 function
18:31right there is a huge blood vessel that takes all the blood to the legs
18:35and so we really want to avoid all that
18:37the use of the roadblock makes this surgery incredibly accurate
18:43why does the accuracy of the screws matter well we're trying to avoid hitting the nerves the spinal cord
18:48and the peripheral nerves the corda equina if we put a one of these anchoring screws
18:53into the nerves that could lead to pain to numbness to weakness
18:57so this is the fracture level the tricky broken bone bit so um we don't know what we're going to capture
19:19really
19:22the 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
19:47putting that screw deep into a blood vessel or into a nerve and obviously that's absolutely not where we want to be
19:57the 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
20:27consultant neurosurgeon mr subawali feels empty doesn't it is performing spinal surgery on 64 year old keith
20:42to 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're gonna open up
21:03a fine incision exposes the space beneath get a hook in there watch out come out with the knife
21:15come out with the knife
21:18so
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
21:45there okay that might be enough exposure so let's try and keep the arachnoid intact if we can
21:53we've opened the duro this bit
21:56this 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
22:07csf cerebrospinal fluid must flow freely in the spinal cord
22:12it's vitally important to get the csf flowing as quickly as possible if there is a blockage it can
22:20cause build up of pressure within the spinal cord and affect the function below the level of the
22:25blockage and in some cases if that pressure is permitted to remain high for an extended period of
22:31time it could lead to paralysis
22:33this 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
22:51the membrane looks swollen something beneath is distorting the space
23:01what the hell is this
23:11what's going on here
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
23:46this is a lobster good this is a padlock well done this is a glove this is a monkey
23:53but before he can cut into her brain he must map out the size and exact location of the tumor
24:02this is a spider good what you find is is as you start to get close to the bits of brain that are
24:09important for you talking or understanding speech this is a um tiger now what we see with linda is she
24:17starts to make errors she starts to struggle with finding the right word for things and that tells me
24:23hold on i'm starting to get a bit close did you stimulate them that was straight away i think
24:30this is a speech isn't it so the tumor's all under here when i stimulate that she stops being able
24:39to talk so we're going to stay away from that bit professor broadbelt has mapped the tumor's edge
24:48marking the boundary between cancer and the adjacent speech center right knife please
24:59it's knife to tumor she washed her face
25:07specialist speech and language therapist give me your sweets hannah jones reynolds must keep
25:14linda talking you sleep in a bed every word means her speech is safe blue is a color so hannah i'm going
25:24to be um getting closer now keep you talking daily he cooks the dinner oh i wish oh are you the main cook
25:34then are you linda yeah yeah and daily the little boy sits under a desk you're doing very well and we're on
25:41the um bit i'm most worried about daily defenses well done professor broadbelt is cutting right at the
25:50edge of the speech center straight micro scissors basically every millimeter matters
25:58daily heat uh the starch is a a person uh struggled a bit there i'm worried my worry is is that all of that
26:09is gonna be speech linda's tumor is large removing it is as vital as it is dangerous this is a um
26:20spinning wheel yeah hesitation again
26:35that's the arachnoid there
26:39mr sabawali has reached a critical point in keith's spinal surgery
26:45this 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
26:56so it looks like the problem that the patient has experienced is because of a cyst
27:09where the arachnoid should have been there's this thicker membrane which is the lining of a cyst
27:17spinal arachnoid cysts are rare accounting for only one to two percent of all lesions on the spine
27:24so it's got a membrane which is this tissue here and then fluid just accumulates within it
27:32so what we'll do is we'll try and remove as much of the lining of the cyst as we can focus
27:38to give keith the best chance of regaining sensation in his legs the blockage must be removed to restore
27:50the flow of cerebrospinal fluid just cut it out all that is not normal all that
28:03the 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
28:10the cyst wall can send microscopic tendrils into the cord but chasing every last cell risks damaging
28:20the spinal cord it's a root isn't it it's stuck through a root
28:26see there's a balance in terms of trying to get as much of it away without risking damaging the spinal
28:32cord in the process it's almost like they're one it's not two distinct layers anymore
28:38i mean you can get it all off but at what cost
28:46i think you've got csf flow there restoring the flow of csf is vital to keep the nervous system
28:53functioning when we opened up there was no flow of csf because the cyst was in the way
28:59so once the cyst has been removed now we can see the spinal fluid can flow above and below where the
29:04blockage was so that's looking a bit more normal now agree all right
29:15now 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
29:26best case scenario after an operation like this is that i would hope that he would notice some
29:31change in the sensation in his legs in a positive way
29:36the operation appears to have gone well but for keith the real test will come in recovery
29:51so
30:00morning good morning how are you oh not so bad thank you so operation went really well that's good
30:06we found a cyst inside your spinal cord but we managed to get most of the lining of it away
30:14so chances of it recurring is very small but not impossible right um but i would expect that you
30:19would get immediate benefit really from us having done i have i can actually get feeling in my foot
30:24because one of the nurses walked past last night and touched him i could feel it that's good so
30:29immediately already finding some benefit in terms of improvement in your symptoms so that's really good
30:35all right thank you doctor thank you very much all right with rehabilitation and time the outlook for
30:44keith is bright the feeling has come back a lot faster than i thought just got to get up now and
30:51there because you'll get about a bit they take more holidays can't wait
31:12back in the trauma theater mr carlton bland and mr stovale
31:16are using a cutting-edge robot to fix bruce's broken spine plan a is still on the tricky broken
31:24bone bit they've reached the most critical stage of the surgery
31:30attaching screws to the fractured part of the spine
31:35so we're not sure how much of a bite we're going to get at the fracture i'm going to just put the short
31:40screw 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 yeah that's as far as we're going to be
32:04able to go on that everything felt not bony everything felt quite soft so there was probably
32:12some blood clot there and we may have well been feeling some of the muscle or even potentially
32:16some of the anterior structures so we took that decision that we would compromise the hold a little
32:21bit but you know reduce the risk of us actually hitting a vital structure
32:28on one side the short screw has failed to grip we're trying the other side now
32:34everything now rests on the second side holding firm
32:44so we're having some sort of real purchase of the screw in the bone
32:49gets a 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
33:01bone 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
33:44there are 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
33:57out the other side that's the only thing that's just well we will find out
34:13we're right next to it straight like scissors please 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 sweet among them are awake craniotomies this is a hat performed only a few dozen times each
34:47year this is a course 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
35:05professor broadbelt is operating on 62 year old linda this is a a rhinoceros hesitation now
35:16he's cutting just millimeters from the area that controls speech
35:21this is a spider this is a um a spinning wheel yeah hesitation again okay this is a um
35:30bird and again twice in a row so we're obviously pretty close you're doing amazing linda scissors
35:38microphones this is a spoon yeah this is a squirrel good
35:42good he's carefully separating tumor from healthy brain this is a um uh oh struggling there
35:54well you're doing fantastic you can keep going a little bit longer that would really help
35:58it to do all around this is a flower bound this is a sofa this is a turn which is a centipede um
36:08caterpillar struggle then okay i'm going to give you a big chunk of tumor very very明 slaughtered
36:14forceps please
36:15so there's a good chunk of our tumor the tumor will be sent for analysis to guide further
36:28treatment and everything okay Hannah there yeah she's speaking really well really well
36:34so I'm just gonna have a little look around the area that affected you so if you just keep talking
36:41okay this is a bed this is a fly this is a bear that looks all right you know this is a bell this is a
36:55belt so I think I've probably done as much as I need to do it looks like I'm pretty much to healthy
37:00brains and she's still talking which is all good this is a carrot you can relax again now I think
37:08we're done oh fantastic how good you've done absolutely incredibly Linda well done are you
37:13happy yes I'm happy yeah happy it's over happy it's over exactly the tumor is out and Linda's speech is
37:23intact so there's the hole speech area there and the brain looks healthy underneath and right time to
37:35close I think it went well and it was useful having her awake and if I was a little bit too generous
37:44with where I was going and it stopped to speaking so we just came back and was able to get everything
37:51they looked abnormal out so that's good three days after her surgery Linda is off and about great news
38:09going home I can't actually believe that somebody's been operating in my brain and that I come out speaking
38:18like I am my voice sounds exactly the same as it normally does really good I'm going home it's
38:25actually you know when it suddenly filled oh yeah I actually felt butterflies and excitement yes
38:29just like hit me a bit yeah I'm actually it's actually happening
38:45in the trauma theatre robotic spinal surgery on 64 year old Bruce has reached a crucial moment but I'm not sure if I'm on 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
39:00doing well Matt
39:02Mr Carlton Bland and Mr Stovell have spent the past three hours working in tandem
39:10should go down that hole that we made
39:13pelvic screws 10 centimetres long and a centimetre wide
39:18huge bits of metalwork transfer his body weight from the good bone above the fracture
39:22down through to the good bone below the fracture essentially taking the weight
39:27so it doesn't move as much and so it can heal together
39:30now the brute force phase securing the screw to the pelvis
39:37there's so much force required I'm actually having to hold the pelvis
39:43from underneath 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
39:56it's the 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
40:20one anchor in
40:22but he needs two
40:24we're on the last screw now
40:25the second screw falls to Mr Carlton Bland
40:28the tough part
40:35yep lovely lovely lovely lovely that's looking good that's what we want
40:44let's cross the joint yep that's fine
40:52okay x-ray there please
40:58the moment of truth an x-ray will show if the scaffold lines up to bridge the fracture
41:14great okay that's great thank you
41:17good news uh the robot has helped us put these trees into exactly where we wanted to be
41:23so that's really reassuring and so now we're going to link all of these anchor points these
41:27screws together to pass the body weight through bypassing the fracture
41:37Mr Carlton Bland threads titanium rods through the holes in the screws to form a rigid scaffold to support the spine
41:44with the construct secure the guides can be removed and the incisions closed
42:00you can look at this broken bone and put in some metal work and the x-rays look great but you don't know how the
42:05patient's going to respond and so um we do the operation we close up and we kind of twiddle our
42:10thumbs and we wait and it's an anxiety provoking time it's like waiting for exam results
42:26after an anxious 24-hour wait bruce is recovering on the ward
42:37oh 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 very
43:00thank you very much no that's quite all right that's what we're doing cheers then right and we'll see
43:05you again okay thank you very much thank you
43:10he's a lot more comfortable than he was before the operation he could hardly move or roll so uh
43:16i think that's a really really good result he's got no nerve problems which is great uh and so we'll
43:21begin the process of building him back up and mobilizing him and getting him up and on his feet
43:26i've always wanted to do a parachute jump you know um but who knows to me right now at this moment the
43:37world's my oyster and it's down to the the staff everybody who's been involved i can't thank them all
43:44for pulling off it's been brilliant
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