“Inoperable” and “incurable” are words not commonly found in Florida Hospital Neuroscience Institutes’ vocabulary list, especially as technology has grown by leaps and bounds. With its medical pacesetting Minimally Invasive Brain Surgery (MIBS) program and advanced Leksell Gamma Knife® Perfexion,™ the Neuroscience Institute is transforming the future of healthcare. With the addition of the new neurosurgical suites and InnovatOR suite in 2011, Florida Hospital has continued to set the medical bar, as the largest, most technologically equipped facility of its kind in the nation, including the latest minimally invasive techniques to treat patients with neurosurgical diseases of the head, brain, neck and spine. Rather than traditional open methods or invasive brain surgeries, the Florida Hospital Neuroscience Institute’s goal is to find less invasive treatments that offer less pain, quicker recoveries and better outcomes than traditional surgeries to patients who often are dealing with brain lesions considered by many to be hard to reach, high risk or inoperable.
The multidisciplinary MIBS program includes treatment options such as Gamma Knife® Radiosurgery, endoscopic brain surgery, endoscopic endonasal skull-base surgery, endoscopic posterior fossa surgery including microvascular decompression, acoustic neuroma surgery, and interventional neuroradiology therapies, including aneurysm and arteriovenous malformation treatments. The MIBS program is only a small part of the Neuroscience Institute, but it is the combination of traditional neurosurgical approaches with the MIBS option that has made Florida Hospital’s Neuroscience Institute an innovative national leader in neurosurgery offering enhanced options for brain and spinal diseases.
The MIBS, Gamma Knife® and Neuro-Oncology Programs benefit from a multidisciplinary team approach where patients are reviewed by a team of specialists, and any necessary tests are performed to ensure that all alternatives are considered when trying to evaluate the best option of care. Every Friday specialists with Florida Hospital meet to review approximately 15-20 weekly case studies and decide on a consensus of care. This group is comprised of specialists from neurosurgery, neuroradiology, radiation oncology, neuro-oncology, neuropathology, neuro-otology, neuropsychology, clinical trials nursing, otolaryngology and interventional neuroradiology. Dr. Robert Sollaccio, Medical Director of Radiation Oncology of the Florida Hospital Cancer Institute and Co-Medical Director and Co-Founder of the Gamma Knife Center, helped to initiate weekly Friday “tumor boards” in 1996, and it’s still one of the most integral parts of the program’s practice to this day. Every team specialist has valued input after seeing the patient, and the group ultimately determines the best course of treatment including less invasive options whenever possible.
One of the most popular and least invasive procedures is Gamma Knife® Radiosurgery. This technology uses extremely precise potent rays of radiation that are targeted like a missile to the abnormality in the brain without affecting any of the surrounding healthy tissues, surpassing virtually all other modalities for treating tumors of the brain in terms of safety, accuracy and effectiveness. Often referred to as bloodless brain surgery, Gamma Knife® has an accuracy of up to 0.3 millimeters. This non-invasive procedure typically requires light sedation and does not involve some of the risks associated with open surgery such as infection, bleeding or stroke. The procedure usually takes 30 minutes to an hour, and patients can usually resume normal activities within 24 hours, much faster than traditional open-cranial methods. Typically, patients are treated as an outpatient and can leave the hospital the same day. With other MIBS procedures, the length of stay is also much shorter than with traditional approaches. Most patients return home in at least half the time they would with traditional approaches.
“We have one of the most advanced programs in the world,” says Melvin Field, MD Neurosurgical Director of the Florida Hospital Neuroscience Institute. “Not long after the 2011 launch of Florida Hospital Orlando’s state of the art neurosurgical suites and InnovatOR suite, other hospitals, including some of the unexpected big-name facilities, were coming to us to learn what we were doing and how we were doing it,” explains Dr. Field. “For several years now, Neuroscience Institute specialists and I have been going out and teaching and proctoring other surgeons, many at academic institutions, about these less invasive procedures and how to use these new technologies to improve the care of their patients at their institutions. It’s always interesting to see patients from Central Florida who think they need to go north for neurosurgical care and then are sent back by those neuroscience centers they visited to Florida Hospital Orlando for treatment. There’s no reason to send someone far away to a hospital when we have everything right here.”
Field is quick to boast the supportive and innovative thinkers who are committed to the best possible quality of care, technology and minimally invasive procedures at Florida Hospital. “The hospital is not only willing to invest the dollars to give us the best of the best in the OR, but they are all on onboard and invested in patient success and being the number one source for patients in Central Florida and beyond.” says Field. “Florida Hospital is committed to going the distance to be number one for medical advancements and cures for seemingly incurable problems for children to adults. That’s why they have also brought in top specialists who are concentrating on epileptic disorders, brain tumors, brain imaging and magnetoencephalography (MEG), minimally invasive spine surgery and interventional neurovascular surgery. These doctors are now offering cures when little to no hope was offered prior to their arrival in Orlando.” The Hospital’s Neuroscience Institute will also be once again showing its investment when it debuts the new Leksell Gamma Knife® Perfexion™ in late August 2013, allowing its team to treat even more pathologies of the brain and upper cervical spine.
Since his arrival to Orlando in 2003, Dr. Field has had numerous patient success stories and was instrumental in the specialized needs and design of the state-of-the-art neurosurgical suites that opened in 2011. Field incorporates various minimally invasive brain surgery treatments such as endoscopic endonasal skull base surgery, endoscopic microvascular decompression, Gamma Knife® and brain port surgery into the surgical care of his patients. He has performed over 500 endoscopic skull-based surgeries in Orlando, and lectures regularly both in and outside the U.S. about MIBS techniques and outcomes. He is passionate about integrating a multidisciplinary approach to the care of his patients. “Putting the minds of many clinicians of multiple disciplines together will always result in better outcomes in patient care,” Field says, noting that he spends more time in the operating room with other surgical subspecialists than not. “There are always more than one or two options to treat any problem of the brain. Our program’s job is to be able to offer all the options, determine which ones are best based on the uniqueness of each patient’s problem, and then treat the patient based on their individual goals and the best existing evidence-based medicine.” Using this approach, Field and his team have treated numerous local and statewide patients and have increasingly seen the number of out-of-state and international patients rise since the program’s debut.
“Recently, I was able to treat a 15-year-old girl from Puerto Rico whose family had been told she had an inoperable and incurable brain tumor,” says Field. “Told it was incurable and there was no hope, the family found out about our Institute and the MIBS program. The whole family flew her in to see me. They refused to give up, and I am glad they didn’t. “The family stayed at a hotel on our campus that offers discounts so they were close and felt a part of the process. I examined her, sent her to specialists and our team reviewed her case study at the Friday multidisciplinary tumor board. We determined we could avoid open skull–based surgery and still remove her tumor with no incisions through a simple endoscopic MIBS approach, called the expanded endonasal approach, through the natural openings of the nose — methods not found in Puerto Rico. Her surgery was done in a team approach with, Brian Spector, MD, who specializes in endoscopic skull-base surgery from an ENT perspective. Using the intraoperative MRI, we were able to confirm the removal of the tumor. By incorporating a novel reconstructive technique developed a few years ago in South America called a septal nasomucosal flap, we were able to get to and repair areas of the skull base to remove the deepest components of the tumor that other neurosurgeons thought was impossible. She was discharged from Florida Hospital the day after surgery without complications, and now she’s a healthy, tumor-free teen, living a normal life back home. Because of other cases like this, we’ve been invited to and have traveled to Puerto Rico helping teach some of these MIBS procedures to neurosurgeons at the University of Puerto Rico, hoping to allow patients to stay in Puerto Rico if such treatment is needed in the future.”
Dr. Field credits the success of the Neuroscience Institute to a total team effort of several innovative specialists and their knowledge, and a hospital staff that is committed to creating and investing the dollars needed to the very best center for patient care in every respect, from technology to specifically trained nurses to care for these specialized recovering patients. Over time Dr. Field has seen the volume of patients increase and is eager to share his knowledge by teaching and proctoring other medical centers.
Of 6,003 hospitals in the United States, only about 400 are teaching hospitals that make up only 6 percent of all hospitals. In fact, the specialists’ ongoing commitment to help educate the medical community and train physicians and medical facilities has become a cornerstone of the Institute and reaffirms its mission to provide patient access to compassionate care of the highest quality of treatment.
In the grand scheme, MIBS is just a small part of what the Neuroscience Institute offers, but its goal is to continuously try to make it better for patients and participating doctors. “We are the largest provider of critical care on a number of levels—the largest in the country with neurological suites for specialized surgeries, state-of-the-art technology, some 120 beds in our neurocritical care and neurosurgical units after surgery, and specially trained nurses and after-care specialists,” says Dr. Field.
“I had a patient from South Carolina who flew in the day prior to treatment after his case was reviewed at our Gamma Knife Conference where it was determined Gamma Knife® Radiosurgery was the recommended option for his benign tumor,” says Dr. Sollaccio. “He was seen in consultation by our team, treated successfully the following morning, and flew home and back to work the day of the procedure. While we do not typically recommend patients return to work the same day, Gamma Knife® Radiosurgery is often the least disruptive option for patients who feel they have no hope. It can truly be life changing.”
“I also recall a young woman in her early 30s, referred to me several years ago in August. I can still recall the beautiful scarf she was wearing,” says Dr. Sollaccio. “She was wearing it to cover all but her eyes. When I inquired as to why she wore the garment in such a fashion, my appreciation for how debilitating some diseases can be grew as she explained…. the scarf was to protect her from painful attacks triggered by air particles moving across her face as she walked. Her pain, due to a disease known as Trigeminal Neuralgia, was an extreme case that demonstrated how day-to-day activities can be negatively impacted. I could feel the pain as I looked into her eyes as she described her attacks.”
Dr. Sollaccio says she was properly diagnosed by her neurologist with Trigeminal Neuralgia but treated more traditionally with medication for several years, until the medication was no longer effective and her doctor referred her to Florida Hospital.
Trigeminal Neuralgia, a severe pain syndrome, is most often due to blood vessels compressing the trigeminal nerve, which originates from the brain in the cerebellopontine angle. This neurovascular compression causes irritation of the nerve and was causing spontaneous attacks often provoked by even the mildest stimulation of the face. Trigeminal Neuralgia typically affects women more often than men, and is more likely to occur in people who are older than 50, so to see someone so young with such a severe, long-term case was surprising to Dr. Sollaccio.
“The pain from Trigeminal Neuralgia is debilitating and can severely impair the patient‘s ability to function,” explains Dr. Sollaccio.
Her case was presented at the team’s tumor board, where it was recommended she undergo Gamma Knife® Radiosurgery. She was treated as an outpatient the following week. Her treatment, consisting of 80 Gy to the trigeminal nerve, was completed within 30 minutes. She returned home by mid-morning and within 4 to 6 weeks of treatment was slowly weaned off her medications. “She is now living a normal, scarf-free, pain-free life after minimally invasive radiosurgery, which is very rewarding, especially considering the alternative option of open surgery,” says Dr. Sollaccio.
In 1996, Orlando was among a small number of cities in the country offering Leksell’s Gamma Knife® Radiosurgery machinery, putting Florida Hospital Orlando on the map as a top medical facility with some of the best medical specialists already brought onboard. But it continues to grow and change the face of innovative medical care. The new Leksell Gamma Knife® Perfexion™ — also known as the Gold Standard of Excellence — will allow Florida Hospital’s Gamma Knife® team to treat even more areas of the brain and skull base, including multiple lesions at once and in a shorter time.
“In late August 2013, the new Leksell Gamma Knife® Perfexion™, a fully integrated system, will be completely installed and ready for use. Leksell Gamma Knife® Perfexion™ will expand patient eligibility by allowing us access to even the most remote areas of the brain, base of skull and upper cervical spinal region,” says Dr. Sollaccio. “Leksell Gamma Knife® Perfexion™ offers impressive speed and automation, shorter treatment times and improved efficiency. Ultimately, this latest technology, when combined with an elite team of caregivers with tremendous experience, will result in the best outcomes and the best possible patient experience. Leksell Gamma Knife® Perfexion™ will allow us to treat separate areas of the brain through a single setup and treatment, rather than the more time-consuming approach with older models that necessitate separate setups and treatments when targeting more than one area.”
Gamma Knife® Radiosurgery starts with light sedation, to minimize anxiety, and topical anesthesia followed by placement of the Leksell stereotactic headframe by a Gamma Knife® trained surgeon. After some measurements, the patient is transported to the radiology department where a treatment planning study, typically an MRI, is obtained and downloaded to the Gamma Knife Center’s treatment planning system. Nina Nguyen, Florida Hospital’s lead Gamma Knife® trained physicist, then works with the treating surgeon and radiation oncologist to outline the target, prescribe the appropriate dose and custom design the best treatment plan for the patient. With Leksell Gamma Knife® Perfexion™, highly focused beams of radiation from 192 Cobalt-60 sources are finely tuned to sub-millimeter accuracy. The target is treated with the appropriate dose of radiation conforming to its exact size and shape, shrink-wrapped so there is little to no collateral damage to the surrounding healthy tissues. While most sleep during the treatment, all patients are encouraged to bring their favorite playlist as music is played during the procedure, typically lasting 30 minutes or less. The entire process is usually complete by mid-morning, when the patient is released after a light breakfast and an hour of observation. Gamma Knife® Radiosurgery can be as easy and pain-free as taking a quick nap during an MRI, but while actually having minimally invasive brain surgery that can be done without incisions or cranial invasions that create longer treatment and recovery times.
All specialists and assisting care specialists of Gamma Knife® Radiosurgery are certified through specific and mandatory training by Leksell, the manufacturer of the machine. “We cannot teach Gamma Knife® surgery to other inquiring doctors and hospitals, only proctor, since authentic certification MUST be provided through Leksell approved and sponsored facilities,” says Dr. Sollaccio.
There is something almost always available for patients who come to the Florida Hospital Neuroscience Institute. With all its new technology, they are more often able to successfully treat patients who were previously considered too ill to undergo a procedure involving the nervous system. The Florida Hospital Neuroscience Institute with the MIBS and Gamma Knife® Radiosurgery Programs, elevate and broaden the standard of treatments and options available to patients in this region. Their goal is to keep growing, researching, innovating and adding technology in hopes of never having to turn anyone away, especially without a minimally invasive cure or treatment plan.
“Although we have made amazing strides in the past five years, this is just the beginning,” says Field. “We are continuing to push the envelope, and I promise that some of the things that we are now working on and plan to bring to Central Florida soon will likely have a bigger impact on our field than anything we’ve seen in the past 50 years.”
For more information, on the Florida Hospital Neuroscience Institute visit www.floridahospitalneuro.com.
525 East King Street, Orlando, FL 32803
By Leigh Duncan