The Innovative Clinic (1991)

To understand the Innovative Clinic Model and my place in medtech, study the American moon program to find my time-tested paradigm of research with over 100 people, now in its 38th year: Unrelenting incremental advances, starting always with needs that only a neurosurgeon can identify to improve surgical results.

The neurosurgeon’s place is a lonely one as the mind operates on mind. Surgical technology is fundamentally a scientific quest. I wrote in 1996, “The process of innovation can be summarized as follows (Fig 2. above): Surgical and other clinical management is the source of the needs for technological solutions. The clinically defined problem is specified for interdisciplinary research.

The resulting technology is transferred to industry, which in turn relies on scientific assessment of the product. The clinic benefits by being able to provide better service. Thus, the "by-products" of the innovative process are scientific publications, exported goods and improved clinical service. It is the level of sophistication of clinical services that defines tertiary care”

Reference:

http://cc.oulu.fi/~emk/koivuk.htm

John Koivukangas: The Oulu Neuronavigation Project -- and Beyond. TECHNOLOGY TRANSFER BETWEEN RESEARCH INSTITUTES AND INDUSTRY, June 7 - 8, 1996, Oulu and Rovaniemi, Finland, edited by Eero Kouvalainen, Timo Jämsä and Kalevi Kiviniitty, published by the Biomedical Engineering Program, University of Oulu, 1996. ISBN 951-42-4409-5.

Our Solution: The Birth of Modern Neuronavigation

M.Curie was once asked why she studied radium. She answered: "Because the bibliography is so short."

Our early work in navigation was based on intraoperative ultrasound imaging since 1980. Surgical imaging consists of three parts: Preoperative, intraoperative, and postoperative imaging. Intraoperative ultrasound and MR imaging continue to be to this day the very cutting edge of modern technologies, some 40 years later.

When MRI came, we wanted reformats in the plane of the ultrasound image. One helped to understand the other. And we used ultrasound imaging to verify the accuracy of our new navigation system, one of the earliest in the world.

Watanabe had reported on a mechanical arm, while optical tracking would come later. Others, including peer reviewers of our manuscript in 1991 concluded that surgeons will want orthogonal images, the familiar axial, coronal and sagittal ones of atlases. But we were bridging to a new world of imaging.

We concentrated on visualization and insisted that the surgeon wants to know where he or she is going, hence our seminal "principle of the common axis" for all instruments, now used in image-guided surgery the world over (and in all contemporary VR-AR applications--you may substitute for the sake of simplicity "the common axis" with Point-of-View POV or Field-of-View FOV, that is, where you are looking determines what you see).

To demonstrate our work and in our own small way to disprove the notions of our esteemed colleagues in peer review, we brought the system to the operating rooms of the Department of Neurosurgery, University of Minnesota, during 1992-93.

Our paper was finally accepted in 1993.

The image above shows the first known actual surgical demonstration of one aspect of the principle of the common axis, namely coplanar MRI/US navigation: the intraopeative ultrasound and reformatted preoperative MR images are from the identical plane. The common axis can be seen in both images - this is to give the surgeon, once again, an intuitive understanding of where exactly s/he is going.

Benefit? US shows in real time that we are avoiding vascular structures. MRI shows the contrast enhancing tumor part for biopsy. This method is used in image-guided surgery centers the world over. And our principle has since been incorporated into all image-guided systems, including the guidance of surgical robots.

Credits: Oulu University Hospital, Oulu, Finland, Onesys Oy/Inc, Oulu and Minneapolis.

Reference shows the "principle of the common axis" for both imaging and an array of instruments: Koivukangas J, Y Louhisalmi, J Alakuijala, J Oikarinen (1993) Ultrasound-controlled neuronavigator-guided brain surgery. J Neurosurg 79: 36-42.

The Clinical Problem (1980)

As intraoperative ultrasound imaging together with MRI and navigation are continually being improved. please let me share with you how I got started early in my career:

The anatomy of the brain is beautiful, whether it be blood vessels for aneurysm surgeons or the brain itself for me. The image shows the surgical field for a low-grade glioma, a small one in a gyrus, but which one and how positioned? CT had just been invented and diagnosed it while still small - MRI was still to come.

In the operating room we only had ultrasound imaging available, hence the start of my long career in surgical visualization of the brain.

My doctoral thesis 1984 on real-time ultrasound imaging is our story among 4-5 early groups in the world.

Koivukangas J (1984) Ultrasound imaging in operative neurosurgery: An experimental and clinical study with special reference to ultrasound holographic B (UHB) imaging. Doctoral dissertation. Acta Universitatis Ouluensis D 115. Oulu University Printing Center.

In the thesis, pp 42-91 is thorough history, 96-97 the problem described above, 100-101 the first description of serial imaging of tumor resection, followed by an exhaustive bibliography.

Critically acclaimed by Dohrmann 1985 in Surgical Neurology.

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