Gamma Knife, Robotic Spine Surgery and the Limits of Current Technology

Awake craniotomy, used for tumours near the motor cortex or speech areas, requires full patient cooperation throughout — some patients become agitated under partial sedation and we've had to convert to general anaesthesia. For international patients, a translator has to be present in the operating room the entire time, which adds another layer of difficulty. Personally I'm not very keen on it given how demanding it is for the patient; we now prefer using preoperative functional MRI to map eloquent areas and then operate under general anaesthesia while avoiding those mapped regions, which reduces the need for awake craniotomy in many cases.

Small vertebral hemangiomas are benign and don't require treatment unless they cause problems. If it's a large hemangioma involving the pedicle, causing vertebral body destruction, or resulting in a fracture or neural compression, then decompression and spinal fixation are required. Share the MRI report with the Jivo team and we can assess based on size and extent.

Communication is key. I'd suggest two things: topic-oriented sessions on one specific subject at a time — lumbar spine surgery, or brain tumours — where everyone shares experience and problems and we learn from each other, since doctors from Africa and India face similar socioeconomic challenges. And continuous feedback after a patient returns home: the local doctor monitors recovery and communicates with us on repeat imaging and medication adjustments. That collaboration, by WhatsApp or email at any time, directly improves outcomes.

For intractable epilepsy, we prefer other surgical methods first — removing an identified lesion (medial temporal lobectomy, or hemispherectomy in appropriate cases). If no focus is identifiable and epilepsy remains uncontrolled, electrodes can be placed in the anterior thalamus, with roughly 70 to 80% success; vagal nerve stimulation is the alternative. For psychiatric disorders we have done some frontal DBS placements, but results are variable, the procedures are not curative, and patients still need to continue medication.

The main issues over time are battery depletion (non-rechargeable batteries need changing every 5 to 7 years, rechargeable systems last around 15 years), electrode disconnection or failure from trauma or mechanical wear, and the need for settings adjustments as the disease progresses. Patients need periodic visits for reprogramming, though newer devices allow remote setting changes via mobile. Battery change is the most common long-term issue.

Small meningiomas, perioptic tumours, vestibular schwannomas, residual tumours after prior surgery, AVMs and metastatic lesions, delivering focused radiation without open surgery.

Intraoperative 5-ALA fluorescence: a dye taken before anaesthesia makes high-grade glioma tissue visibly fluoresce a different colour from normal brain under a filtered microscope. Neuronavigation and intraoperative MRI are also used to localise tumours and confirm complete resection.

Near-perfect, pre-planned placement, with significantly reduced radiation exposure to both patient and surgical team.

Not yet. The robotic arm places screws, but nerve decompression still requires a surgeon working under a microscope or endoscope. Manufacturers are developing robotic decompression, but it is not currently available.