Spinal imaging technology has eliminated many mysteries in patient care, but there are still areas to grow, Robert Rothrock, MD, director of spinal oncology at Miami Neuroscience Institute, said.
Dr. Rothrock spoke with Becker's about the evolution of spinal imaging and how it will affect spinal oncology care.
Question: How has innovation in 3D planning and radiosurgery evolved in spinal care throughout your career?
Dr. Robert Rothrock: One of the best things about my job, aside from helping people, is that even within the community of neurosurgery, I feel that a lot of the technical advancements that have happened over the last 10 to 20 years have really landed in the realm of what I do.
We now have not only access to, but an imperative to utilize newer technology, because one of the things that has changed is not only what we're doing in the operating room, but how we're thinking about it preoperatively. Three-dimensional modeling is something that 10 years ago, a lot of people saw as more gimmicky. But at our institution, we've had access to 3D models based on preoperative CT scans that lets us very quickly see and appreciate spinal anatomy and preexisting hardware. It can identify very quickly preexisting hardware and subtle anatomical findings.
This can be very useful because with 2D spinal images, it can be easy to miss subtle spinal deformities that maybe then you encounter at the time of surgery. Three-dimensional modeling eliminates the remainder of the guesswork that was still left. In the modern era, we don't have a lot of mysteries left. We might find things once in a while that we didn't expect during surgery, but most of what we see is what we think we're going to see based on preoperative imaging.
Q: Of the mysteries you're saying, are there any that still remain or common things 3D planning might miss?
RR: Just to allude to what mysteries still remain, often in spinal oncology, we're dealing with tumors where we don't know the exact type or diagnosis preoperatively. This is most common when dealing with acute spinal cord compression, where you don't have time for a preoperative biopsy. That's important because you might have a situation where a tumor may be radiation-sensitive versus a primary tumor, which is not, with very different treatments. 3D planning currently doesn’t help with this issue.
What I have seen is that sometimes with 3D modeling, we can see a more subtle spinal deformity that maybe you would miss with two dimensional imaging. For instance with rotational deformities, that is one of the things I think that's evolved over time with spine surgery. We've learned how to get better, but we've learned that through historically making mistakes. I think we have to own that as a spinal surgeon community and learn from it, and not let it happen anymore.
Q: How is radiosurgery evolving specifically in spine oncology?
RR: Radiosurgery is high-precision, image-guided radiation treatment. The word is a bit of branding, but it's supposed to convey that it's a very high-precision and higher-dose treatment. Some have argued that spinal radiosurgery really helped create the field of spinal oncology, because prior to the existence of these really effective radiation treatments, most patients with spinal metastases were treated as hospice patients. As we've gotten better with treating primary cancers; people are now living longer with cancer. The ability to treat spinal tumors with radiosurgery allowed for much better local control, meaning the ability to actually locally cure or at least keep that tumor from growing. Now patients who used to die or progress to paralysis within six months can live five years or 10 years or a normal lifespan depending on their primary cancer. So it has evolved tremendously.
One issue with radiosurgery is that it has a lot of constraints based on the spinal cord and the things around being treated. Part of the evolution of radiosurgery has been hypo-fractionation, which is breaking up the treatment into sessions, which is very normal in radiation therapy. This allowed us to include a lot more patients as candidates for this treatment. So what I would say is that evolution has also been an ever-growing number of persons or patients who can benefit from this treatment. And that's really one of the main facets of medicine, I think, which is taking something that maybe used to be very narrowly applied and now applying it broadly. There's so many different ways that radiosurgery can evolve. One way we're exploring here at Baptist is treating patients earlier. We have a randomized controlled trial to treat patients before they become symptomatic from spinal metastases, and the idea is that maybe this can prevent the need for surgery later.
Q: Five years from now, what will spinal oncology care look like?
RR: I think the trend is that more and more patients will have good, meaningful treatment options as we continue to evolve every day. There will be more candidates for these sorts of beneficial procedures. In five years, ideally, we will be operating less because we're treating things earlier in their disease course.
We have seen, for instance, over the last five years a big evolution in how we treat pathological compression fractures. We have much better implants and devices we can use to stabilize vertebrae without even doing large instrumented surgeries. For the patients with spinal cord compression, we can integrate these technologies to do less invasive surgery, which means less time recovering. Everything we do in treating cancer of the spine has to do with quality of life. We put that first and foremost.