With precision
to perfection

In terms of area, Australia is nearly as large as the United States of America. The two health­care sys­tems are also very simi­lar. In con­trast to other coun­tries, sur­geons in the USA and Australia are classi­fied based on their sur­gi­cal suc­cess. For Australian physi­cians, excel­lence is rewar­ded and errors are punished. Those who are negli­gent in the OR and over­look details lose their patients or do not have many in the first place. This sys­tem rewards passio­nate and ambi­tious sur­geons. 

Neuro and spine sur­geon Timothy Steel of St. Vincent’s Hospi­tal is one of them. After he com­pleted his studies in Australia, he worked in various univer­sity hospitals in the USA and Great Britain and became familiar with different healthcare systems. Now he has been working at St.  Vincent’s Hospi­tal for more than 20 years. The hospi­tal, founded in 1857, is one of the oldest in Sydney. Loca­ted in the red light district near the harbor, it was primar­ily a hospi­tal for the city’s poor. To ensure care for the less priv­i­leged, a private hospi­tal was built next to the public one. Together, both institu­tions now serve the eastern part of Sydney and its sub­urbs. The types of patients and natio­nal reputa­tion of the hospi­tal have changed dra­mat­ically since then. Wealthy resi­dents of Sydney’s coastal region around Bondi Beach are treated here; people from other areas of the country come here for the renowned physi­cians. For Timothy Steel, patients even fly in from over­seas.

Steel has carried out more than 10,000 opera­tions in the last 20 years, nearly all of them are spine cases. He is an expert in his area and well-known in­ter­na­tion­ally. His excel­lent reputa­tion is due primar­ily to his love for preci­sion. He calls him­self a slow sur­geon for whom accur­acy is more impor­tant than effi­ciency. Even on long work­days, when Steel com­pletes five opera­tions in a row, he remains unflustered. Instead, he is thorough and pre­cisely checks the pro­gression as well as the results of the pro­cedure. “For me, it is more impor­tant to work slowly, but accu­rately, instead of having to explain to the patient after the proce­dure that he will have to under­go another opera­tion because my work was not care­ful enough,” says Steel.

This sur­geon wants to operate per­fectly in every proce­dure and intra­operative imag­ing helps him do so. He uses the Ziehm Vision RFD 3D because its image quality impressed him right from the start. He often operates the C‑arm together with his naviga­tion sys­tem, which provides a visuali­zation of sur­gical instru­ments on the current patient data in real time. The quality of the X-ray images of the C‑arm is always the criti­cal factor for this sur­geon. The sharp­er the images and the clearer the bone edges and struc­tures, the more pre­cisely Steel can evalu­ate his pro­gress. For him, the images of the 3D C‑arm come close to those of a CT, but a criti­cal advan­tage of the mobile C‑arm is the pos­si­bil­ity for intra­opera­tive use. The innova­tive C‑arm impressed him, along with the ability to carry out a 3D scan while the patient is still lying on the table. “The C‑arm makes it pos­sible for me to do pro­ce­dures that are faster, safer, and more mini­mally inva­sive. You can’t ask for more than that,” says Steel.

The C‑arm is used for all spine opera­tions that Steel carries out today. He uses it at the begin­ning for exact plan­ning, during the opera­tion to check his pro­gress, and at the end of the pro­ce­dure to exa­mine the results. When­ever Steel is not one-hundred per­cent sure, he takes another X‑ray image or uses intra­opera­tive navi­ga­tion. For Steel, the com­bi­na­tion of mobile 3D imaging and image-guided navi­ga­tion rep­re­sents a mile­stone in medi­cal imag­ing, which makes it pos­si­ble for him to meet his high expec­ta­tions with regard to pre­cision. That wasn’t always the case. Steel still remem­bers the first spine case from over 20 years ago that he attended as a young doctor in train­ing. “It was a spinal lami­nec­tomy in which the sur­geon had to expose the spine as they did at that time. He removed a great deal of muscle and tissue in order to see the verte­bral body. This image stays with me. For me, until that point, spine sur­gery had been some­thing wonder­ful; the truth was a shock to me, com­pletely differ­ent than I had expected,” Steel explains. “Today we do mini­mally inva­sive proce­dures with a small incision with which I can still always see right where I am, thanks to intra­opera­tive imaging.” This method of sur­gery is signifi­cantly less inva­sive; many patients can be released from the hospi­tal either on the same day or the day afer the procedure.

Even though intra­operative 3D C‑arms have been on the market for a few years already, it was the Ziehm Vision RFD 3D that first con­vinced Timothy Steel. The sur­geon found the image quality of earlier sys­tems by various manufac­turers insuf­ficient. For him, the main problem was the visualiza­tion of the anato­my of older patients, who are most fre­quently affected by spinal dis­orders. “The bone structure becomes poorer with age and, as a result, it is no longer as sharply defined on the X‑ray images,” says Steel. At that time, he says, the pre­opera­tive CT did provide signifi­cantly better images, but due to the patient’s move­ment during the oper­ation, the images were never one-hundred percent sure identi­cal with reality. In the mean­time, things are dif­ferent: “The fact that I can take a high quality X-ray image of the patient on the OR table and see the precise anatomy right there in front of me is unbeliev­able. The intra­operative reassur­ance makes my proce­dures for patients of all ages more exact and safer.”

Above all, for Steel, pre­cision means safety: “Spine inter­ventions are risky pro­cedures by defini­tion, primarily when you operate on the spinal cord. During every surgery, I could irre­para­bly destroy nerve tissue; there is no second chance.” The highly com­plex pro­ce­dures can be classi­fied into two types: decom­pres­sion, or the exten­sion of the spinal canal to relieve pres­sure, and fusion or spon­dy­lo­desis, the con­nection of two ver­te­bral bodies for sta­bility. “Basically, I have been doing primar­ily these two pro­ce­dures on the spine for more than 20 years. The pro­cedures them­selves have not changed up to the pre­sent day. We either remove ver­te­bral body parts to elimi­nate pres­sure from the nerve or we con­nect ver­te­bral bodies to sta­bi­lize the spine. But the sur­gi­cal wound is con­side­ably smal­ler today and we hardly need to remove any tissue. In this way, a risky pro­ce­dure with sub­se­quent inten­sive care and a pro­tracted heal­ing pro­cess has become a 60 to 90 minute opera­tion after which the patient can go home on the same day,” says Steel. Looking back on his begin­nings as a physi­cian, he would never have dreamed that this stand­ard would exist: “For us neuro and spine sur­geons, these are good times. The stan­dard for medi­cal imag­ing is so high that it can hardly be any bet­ter. Each gen­er­ation of the Ziehm Imaging C‑arm is faster, better, and has a higher image reso­lu­tion, so it is fun to work with the sys­tems.”