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At the Intersection of Science, Health Care, and Technology: The Center for Surgical Innovation

In many ways, Amanda Shadowens is a typical teenager: hanging out with friends, attending school dances, playing her trumpet. But Amanda also suffers from chondrodysplasia punctata: a rare form of dwarfism that impacts the curvature of Amanda’s spine and can cause a dangerous compression of her spinal cord. Amanda was forced to wear a collar to keep her neck straight, to prevent that compression. But a revolutionary surgery at Dartmouth-Hitchcock promises to change Amanda’s life, allowing her to be an even more normal teenager.

On August 7, Amanda underwent a complex fusion of the upper cervical spine through the mid-thoracic spine. The surgery took place in the Center for Surgical Innovation (CSI) at Dartmouth-Hitchcock, a new, state-of-the-art facility at the intersection of science, health care and technology that was created in partnership with Dartmouth’s Geisel School of Medicine and Thayer School of Engineering.

Pediatric Neurosurgeon Dr. David F. Bauer of the Children’s Hospital at Dartmouth-Hitchcock performed Amanda’s 20-hour surgery, assisted by a team of more than a dozen doctors, nurses, aids and engineers in a procedure involving a variety of fixation devices, screws, and rods to hold Amanda’s spine together in the most-secure, safest manner. As Amanda recovers, four months after the surgery, the results are promising.

VIDEO – Amanda’s story:

“Our goal is for Amanda to have full activity, without any restrictions, and do the things we want children to do,” says Dr. Sohail K. Mirza, Medical Director of CSI and Chair of Orthopaedics at Dartmouth-Hitchcock, and who assisted on Amanda’s surgery, “which is to run around and play without worrying about damaging her neck or spinal cord.”

In the beginning: a dream

CSI combines, in one facility, interoperative imaging capabilities that give surgeons unprecedented ability to see, in real time, the tissue and organs involved in procedures. Designed and built by the Minnesota-based technology firm IMRIS, the CSI configuration combines computed-tomography (CT), magnetic resonance imaging (MRI) and traditional fluoroscopy (x-ray) technology, and is the only hybrid operating suite in the world where both CT and MRI can scan a patient on the OR table with either or both modalities – without moving the patient. The advantages in operating efficiency and patient safety are immense, says Mirza.

“CSI began as an idea – a dream, really – about a facility that could dramatically accelerate and improve surgery. CSI allows us to perform procedures in ways that are significantly better than conventional surgery. We’re looking very carefully at how the technology we use and the procedures we develop will improve the lives of patients.”

In 2010, the National Institutes of Health awarded a $9.3 million grant to support development of the $19 million CSI. The project leverages the research strengths and interests of Dartmouth-Hitchcock and Dartmouth College, including the Geisel School of Medicine and Thayer School of Engineering, in a multi-disciplinary approach to advancing population health. Construction began in June, 2011; the first surgeries in CSI were neurosurgery procedures performed by Dartmouth-Hitchcock Chief of Neurosurgery Dr. David Roberts in the spring of 2014.

VIDEO – Improving brain cancer treatment with fluorescence-guided surgery

“We offer services for very complex, high-risk cases like pediatric spine surgery, like Amanda’s, as well as certain types of brain tumor surgery and spine cancer surgery, that we wouldn’t be able to offer without the technology in the CSI,” says Mirza, who is also a professor of orthopedic surgery at Geisel. “This will allow us to directly contribute to improving the health of local patients and the population we serve in Northern New England.”

Seeing below the surface

Surgeons are too often limited by what they cannot see, including anatomy that is difficult to reach or medical conditions that are not visible to the naked eye. “While advances in imaging such as real-time x-rays during surgery and MRI and CT scans prior to surgery have helped to advance many surgical procedures, further innovation is needed,” Mirza explains. “An example would be the fractures of the second vertebrae in older adults, where a millimeter too long or too much to one side can mean catastrophe if a blood vessel is injured. But with 3D imaging during procedures and things like robotic surgery, we’ll be able to be much more precise and overcome a lot of human limitations.”

VIDEO – Dr. Mirza and colleague Professor of Engineering Keith Paulsen discuss the core principles and opportunities in CSI

CSI enhances Dartmouth-Hitchcock’s nationally-recognized research programs in neurosurgery and orthopedic surgery; leverages research in neuro-imaging and breast imaging to spawn innovative new programs in interventional psycho-therapeutics and intraoperative biomarkers for surgical resection guidance; and augments emerging research programs in prostate surgery, intraoperative oximetry imaging, and in vivo optical microscopy. CSI offers advanced imaging, image-guidance and data collection tools, which will be used to substantiate and/or validate medical discoveries, clinical hypotheses and procedural innovations.

“CSI consists of two operating rooms and two procedure rooms in a long, linear set of suites that will provide intraoperative CT and MRI scanning,” explains Keith Paulsen, PhD, the Robert A. Pritzker Professor of Biomedical Engineering at Thayer School of Engineering and CSI Scientific Director. “The scanners are mounted on ceiling rails, allowing them to move in and out of the ORs. The MRI can go into either OR and the CT can go into one of the ORs, which we call OR 2. That makes OR 2 the only operating room in the world at this time that has both MRI and CT scanning.”

Translating theory into practice

While other institutions have advanced surgical facilities, those spaces are usually reserved for a particular subspecialty area such as neurosurgery or cardiology. CSI is open to all disciplines. Dozens of research projects, led by Geisel and Dartmouth engineering faculty, are being planned and will include the fields of orthopaedics, neurosurgery, oncology, psychiatry, solid organ transplantation, and biomedical imaging.

“Translational research is essential to developing new clinical technologies and procedures as well as for evaluating clinical outcomes,” says Paulsen, one of the recipients of the original NIH grant and whose research interests include medical imaging methodology and cancer therapeutics. “Yet, it has become increasingly difficult to conduct in the current health-care environment because it is highly disruptive to clinical workflow. CSI addresses a growing clinical need for additional surgical and imaging capability, creating more efficient and effective patient care.”

“We anticipate immediate clinical benefit, as imaging modalities are used during the course of orthopaedic or neurosurgical procedures to assess the successful completion of the procedure,” says Mirza. “In addition, we anticipate significant funded research opportunities, both for current faculty as well as for potential future faculty.”


 Note: Thanks to Dartmouth-Hitchcock Communications for writing this article.