October 2017 Edition. Volume XVII

New FiberopticThe providing of adequate Illumination and Magnification are well recognized as being key adjuncts inallowing surgeons to perform successful routine operative procedures. While operating room lights and the operating microscope have represented important advances in this direction surgical fiberoptic headlights have consistently represented the most practical and cost-effective means of illuminating operative fields. Neurosurgical pioneer Harvey Cushing shown below operating in Boston in 1929 experienced this limitation. Attached to his head is a bare light bulb which often burned the forehead of his surgical assistant whenever Cushing turned his head and leaned forward.

CushBost1929

BrodelSurgHeadlight150JPGThe state of the art in illumination during the Professorship of Walter Dandy (successor to Cushing at Hopkins)  has been chronicled in this drawing by  medical artist Max Brödel. The light bulb headlight has been blackened except for its end.  The incidence of burned assistant foreheads was not changed.

 

 

BurtonHeadlight200JPGIn 1967 the Editor was a navy neurosurgeon. Memories of his frequently  burned forehead prompted him to design and patent the first fiber optic surgical headlight.  This new device, (U.S. Patent 3,645,254) was designed with a universal mounting which allowed the beam to be easily moved.

 

OpTel200GIFSince 1967 fiberoptic headlights have come into common use.  Shown here is a headlight being used in conjunction with 9x  telescopes from Designs for Vision. For routine spine surgery the Editor has utilized a 4.5x widefield telescope with a 18″ focal length.

 

The introduction of operating microscope in the late 1960-1970s for the purpose of microsurgical nerve repair and small blood vessel anastemoses initiated a new surgical dimension.  Shown below to the right is a typical modern operating microscope.  As with all innovations the optimal areas of application and inherent liabilities have emerged only with the passage of time.

Microscope Advantages (as with all microsurgical techniques) are meaningless unless a dry operative field is present.  It is only under this circumstance that surgeons can then apply their sophisticated skills.  In neurosurgery, because neural and non-neural tissues (dura, scar tissue, etc.) can often not be reliably discriminated with the naked eye alone the use of enhanced illumination and magnification is necessary under all conditions and is essential under particular circumstances (i.e. the repair of dural tears). The advantages of an operating microscope include excellent illumination and visualization for a small field of surgery and allowing an associate to observe. Video imaging and photographs are added benefits.

Microscope Disadvantages:  The following represent  disadvantages to the use of operating microscopes:

Increased surgical cost.
Increased surgical operating time.
Increased likelihood of infection.
Limits surgeon visualization of the full operative field.

For routine use in neurosurgery, most particularly, spine surgery, the Burton Experience has been that the combination of a fiber optic headlight and operating telescopes are generally superior to the operating telescope for most surgical procedures.  A shorter period of patient anesthesia is associated with a significant decrease in surgical complications. When operative complications such as dural tears occur the failure to utilize adequate magnification and illumination with a full field of vision has often resulted in unnecessary patient problems.

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