"The future ain’t what it used to be ” - Mark Twain

“ What do they know of England who only England know ”  - Rudyard Kipling.

As one  trained in the BC era (Before Computers and Before Christ probably are the same) I am like a dinosaur belonging to the Jurassic Park. In spite of this serious limitation, I will attempt to give an overview as it were, of  the role of computers in neurosciences. 

The super computer: 

The neuroscientist  of today can be compared to a blind folded individual walking across the Grand Canyon. He is expected to  maintain, service and repair  the  most  intricate computer that has ever been or ever will be  produced. Though the original  proto­type was launched almost 7 million years ago, we still do not have even a rudimentary  circuit diagram. In such a situation, is it  reasonable to expect a neurosurgeon or neurologist dealing with the  brain ,to  guarantee an uptime of even 95% ? Though the warranty period is steadily increasing, spares are not yet available. 

The worlds most advanced supercomputer does not contain any silicon. Organic molecules have connected  to form a highly sophisticated network that can communicate, calculate, perceive, manipulate, self repair and even think and feel. Perhaps digital computers can calculate faster and more precisely, but even the simplest organisms are far superior. Computer designers while conceding that the human brain can never be replicated, feel that some special properties of biological molecules can be exploited. Proteins particularly can be used to build computer components that are smaller, faster and more powerful than any electronic devices currently in the drawing board. 

Individual components on semiconductor chips are becoming smaller and smaller. At this rate by 2030 it will approach the size of a molecule. However there is a serious roadblock. Each factor of two in miniaturization increases the cost of production by a factor of five. The search  for smaller electronic devices is going to be limited by economics rather than physics. The use of biological molecules, as active components in computer circuitry may offer an alternative economical approach. Molecules can potentially serve as computer switches because their atoms are mobile and change positions in a predictable way. If this atomic motion can be artificially directed, two discrete ( on /off ) states can be generated. Theoretically a biomolecular computer could be one fiftieth of the 1 micron semiconductor switches used today. It would also operate a thousand times faster. 

Storage of data in three dimensions and use of parallel processing architectures ( where multiple sets of data can be manipulated simultaneously ) is the dream of every computer scientist. Artificial neural networks that mimic learning by association is essential for introducing Artificial Intelligence. The hardware required for this, is available in certain proteins which change their characteristics with light. Hybrid computers containing semiconductor chips and biological molecules will be a reality sooner than later. Unraveling the secret of the structure and function of the neuron, with specific reference to its terabyte capacity, packed in just 1300cc of tooth paste like material will result in the study of neurosciences in computers rather than vice versa. 

Computer technology has revolutionized  our understanding of the nervous system particularly in the diagnosis and management of neurological disorders. Many of the phenomenal developments in neurological sciences have been a spin off from the exploration of outer space. These  include 1) imaging in  diverse structural and functional modes 2) navigation with increasingly complex maps 3) molecular neurobiology and 4) development of complex neuro prosthesis and miniaturized technical adjuvants. The Sojourner rover which was recently used in the exploration of  Mars represents where we are today. This six wheeled land rover was capable of navigating to the designated target  avoiding obstacles and sensing hazards including excessive tilts. The scientists on earth made strategic decisions, while the remote electromechanical surrogates carried them out several million miles away.  The human brain can be equated to Mars and the same technology applied in a clinical setting.

Neurogenetics:

The ambitious human genome project which will identify the structure and function of every one of the 100000 genes in the 26 chromosomes in the nucleus of every cell depends entirely on powerful super computers to analyse the millions of combinations possible with Adenine, Guanine, Cytosine , Thymine and Uracil. 25% of all genetic diseases are diseases of the brain. The genetic basis of at least 40 distinct neurological diseases have already been identified. New ideas will result in new tools and new therapies The neuro-oncologist of the  next  century  will be a molecular biologist.  By the year 2025 the genetic basis of most diseases would have been identified. The  chemical. physiological and genetic basis of several facets of human behavior would have been unraveled. This may result in brain mind manipulation including the manipulation of learning, memory and several types of  emotions. 

Investigating brain tumors:

Several  tools,  currently of an  esoteric  nature,  are likely to be available in a clinical setting. These include magnetic resonance spectroscopy.  MRI at present is  used  to identify the structural pathology of a tumor in the brain. Using sophisticated software the MRI can be used to study metabolites within a  selected region  of interest (the tumor)   Spectral  peaks will   indicate   the   metabolite  produced   by   the   tumor. Millimolecular concentrations of brain tumor metabolites can  be detected  non  invasively.  Metabolic  fingerprinting of brain tumors will eventually be available in a clinical  setting,  as one  more  tool,  to precisely identify the nature  of  a  tumor preoperatively.

Role of computers in surgery:

The present:

Image guided brain surgery: Not content with depicting structure,  imageologists are today  concentrating on  the functioning brain. The result is   a  whole  gamut  of imaging techniques like Trans  Cranial  Doppler, Intra  Operative Ultrasound, PET, SPECT, MEG  (Magneto  Encephalography), SQUID  (Semi Conductive Quantum Interference Device) and so on. To see the unseen, or to  quote the  star  trekkers "to go where no man had ever gone  before" has become an obsession  with brain cartographers Today, using interactive  multimedia kits and sophisticated  visual  graphics. it is possible to image every  wrinkle   on  the  face   and  every  fold on the scalp of   an   individual, The  face and the skull can be  viewed  from  any  direction.  No longer  is  it  simple  antero posterior  or lateral views.  Studying images  of  the brain  today  involves  team  work and   powerful  computer  work stations.  The raw digitized data  can be manipulated as per  the needs of the clinician. Functional imaging is enabling us to take a look at how the brain itself works. Understanding higher cognitive functions, and how information in the motor cortex, visual and auditory cortex is processed  is now being studied in depth thanks to sophisticated computers. Identifying epileptic neurons will pave the way to its removal . 

Conventionally,  the neuro surgeon takes the CT or   MRI pictures  into the theatre and based on his knowledge of  anatomy and  imaging  tries to picture where the lesion is and  the  best method  of approaching it. Easier said than  done. In  real  life even   experienced   surgeons  have  got  lost  on  the   way! Unfortunately  hitherto there was no one to ask directions. The question " where am I " is one which the neurosurgeon  keeps   asking himself   every   few  minutes,  as  he  proceeds   towards   his destination.  The  grey matter and white matter of the  brain  do not  carry  sign posts like  "No entry ", " One way traffic ", "sharp turn ahead ", " watch out - dangerous double hairpin bend "and  so  on. In the abdomen one can always look  around.  In  the brain,  this  can be disastrous and the effects can be  seen  far away. 

Today, thanks to the operating microscope the road to the tumor is beautifully illuminated.  Thanks  to laser,  ultrasound aspirator and other instruments any road blocks can be removed  - once  they  are encountered. However damage can be  done   before  they  are encountered, as soon as  the  journey   has  commenced.  Based   on one's  knowledge  of brain  anatomy and  physiology  a path  is  chosen,  to reach  the   goal., Any  one   would  concede   that  traveling  to  the Artic without a detailed map is bordering on foolhardiness.  Trying  to distinguish   different    areas   in   the  brain,    even   with magnification  is  like trying to distinguish  one  penguin  from another! Yet one had to navigate in the  sanctum sanatorium, with only a diagnostic film for assistance. 

Even a few  decades ago, the brain was  indeed  a   dark continent  - unmapped and unknown. Working overtime, computer savvy neuro imageologists  are slowly  producing a truly comprehensive map which can be  updated in real time. Tomorrows brain surgeon will have maps, as  precise as that in the Voyager mission. Digital technology will make  the description of a surgeon of yesteryear - " eyes of a hawk and the heart of a lion " obsolete. Familiarity with a mouse will be  the order  of the day. " Point and click ",  " Single  click,  double click  ", " Left button, middle button and right button"  "drag and drop"  these  will be the jargon of  the  surgeon  in   the operation theatre. The last few years have witnessed a tremendous growth in interactive  image guided brain surgery - a detailed road map  at last.  The added advantage is,  that this map is updated in  real time.  The  presence  of landslides and  road  blocks  ahead  are broadcast as in a citizens band radio. Reversing one's path  will almost never take place. How is this done? 

Today  with real time interactive image guided  surgical tools   like  "The Viewing Wand" it is possible  to   achieve   a navigation  as precise as that in the Voyager mission. After  all,  the  intricacies and the consequences are none the less . Initial  MRI  or  CT scanning  is  done with markers placed on the patients  scalp which serve as reference points. .  A powerful  computer workstation gives a 3D reconstruction  of  the face.  The tumor is always related to the  external  skin  markers.  The  " Viewing Wand " is a commercially  available   system consisting   of an image processing computer and   a   mechanical arm,  consisting of four movable joints. Each joint consists of a potentiometer  that  constantly  feeds back  its  position  to  a personal computer. Thus the computer knows the position in space, of the end of the arm. Probes of different lengths and shapes can be  attached to the end of the arm. This can act as a pointer  or even as a  biopsy forceps. 

The  Viewing Wand is particularly useful  when  constant reference to the preoperative image is necessary. Locating  small lesions anywhere in the brain no longer requires large exposures. After in putting  all the  diagnostic images into the work station, the wand is  simply pointed  at  the  head,  the lesion  located,  the  approach  and trajectory  planned  and  a minimally  invasive  approach  option chosen.  As one proceeds into the brain using the wand the exact present location, in terms of the diagnostic image, is displayed on the computer screen . It will be possible to eventually input  a host  of data, like physiological functions, angiograms ( study of blood vessels ) and so on.  Thus  one   can   avoid  dangerous  areas.   There is minimal disruption of normal brain, while approaching the tumor. This   technique  ensures  accuracy   and   precision. Accuracy is defined as the ability of a device to locate a  point in  space.  Precision  is the ability to  return  to  a  specific location.  Constant checking and rechecking is possible.  Like  a spacecraft  checking  its  position  continuously  by  the  Global Position  Satellite, the neurosurgeon  knows exactly where he is at any  point of time. Tomorrow's surgeon may or may not be familiar with different types of blades and suture materials. If he or she cannot point, click and drag with a computer mouse he/ she will soon fade into oblivion. In a ever increasing competitive world one has to keep running just to stay  in the same place!   

The future:

In the next century this will be totally different. The emphasis will be on real time functional localization and minimally invasive or non invasive procedures. Today surgery means physical, mechanical removal of a brain tumor. Tomorrow energy in the form of both ionizing and non ionizing radiation will also be used.

Preoperative simulation: The neurosurgeon of tomorrow  will switch on a computer and see his patient's head on a giant screen.  The head will be displayed in three  dimensional  color with every single facial contour and even the impression of blood vessels on the skin,  clearly displayed. The skin and skull can  be  made transparent  and the tumor located in the depths of  the  brain. The  head is rotated 360 degrees in any direction and plane.  The contour  of  the tumor is visualized.  The  relationship  of  the tumor  to  the  adjacent  blood vessels and nerves is displayed.  A  complex picture in which is fused a CT,  MRI,  PET scan, Cerebral blood flow and a host of other  neurophysiological functions is displayed. Using artificial intelligence the optimum least invasive angle of entry is  determined. Using the left button of the mouse, the  incision is  made. Hemostasis is secured with the right mouse  button.  If the frontal branch of the facial nerve has been cut  accidentally ,the postoperative facial appearance is immediately displayed. The computer can even be programmed to say, " Ouch, that hurts ". The entire surgery is carried out on the screen with a mouse.  Superb computer  graphics ensure that the surgeon sees exactly  what  he would   see,  under  the  microscope  in  the   actual   surgery. Alterations   in   blood  pressure,  cerebral  blood   flow   and neurological  function  at every step is displayed  with  warning signals.  The  CT/MRI picture is periodically  superimposed  over "the operative area" so that the exact amount of tumor remaining can be seen. No longer can the surgeon claim to have removed  the entire tumor !  In a few hours the surgeon has optimized the  best treatment  plan. In the real theatre the next day, there will  be no  rehearsals. As all the errors have  already  been  committed, there  is time for correction. Obviously on D day there would  be no room  for flaws. 

Intraoperative functional localization: One  of the major drawbacks in brain surgery is the limitation in precisely localizing brain functions intraoperatively. Even the MRI only demonstrates structure. While  we  know precisely where Broca's area ( speech area )is situated  in  the normal person, it is often forgotten that when there is a  tumor adjacent to the speech area, the speech area itself gets shifted. Post  operative neurological deficit can be avoided  and  tumors removed more aggressively in the future thanks to Functional MRI, Magnetoencephalography, Thermoencephaloscopy, SPECT, PET, Magnetic  Source  Imaging (MSI) and so on. In  MSI  special  detectors, detect  the infinitely small magnetic field produced by current flowing  in   neurons.  Thus it will eventually  be  possible  to identify groups of neurons firing when a particular action  takes place. 

Robots in neurosurgery: Robot guided stereotactic surgery is now available in several centers. Advances   in   engineering,   optics, biomaterials,  artificial vision and micro  miniaturization  have resulted   in  flexible  robots  holding   sensors   (ultrasonic, barometric or visual) Today's robot has a  trunk,  shoulder, arm, elbow, forearm, wrist and hand inter connected with  angular joints.  The fingers can introduce a probe towards a target  with an accuracy of 0.1mm. Tomorrow's robot will have AI (artificial intelligence)   -  a  PC  piloting  the  robot. The command module is an IBM computer in which a robot  programming card is inserted. It houses the software used to pilot the robot. A calibration file translates the Cartesian coordinates given by the operator into the six angle coordinates of the robot. Spatial data describes forbidden areas which the robot’s trajectory must avoid. Once the trajectory is computed it is displayed and submitted for validation to the surgeon. On approval the robot which has been wrapped in a sterile plastic bag starts its approach. X ray controls check that the current position is correct. Correction is made through small displacements triggered from a keyboard. The robot assumes the final position, through automatic detection of the image of the probe holder on digitised radiograms, and comparison with the theoretical target. Once the correct position is reached, the power of the command module is shut down so that  unwanted  movement of the robot cannot take place.. Intelligent stereotactic robots, flexible enough to  support  microscopes, endoscopes, telesurgery, needle biopsies, and aspiration will  eventually be available. 

A robot used in the neurosurgical theatre should have precision and reliability; be capable of performing every kind of routine stereotactic procedure using the same frame and equipment; be driven from various types of neuroradiological images; be safe and permanently submissive to human control; be capable of sophisticated but stereotyped work like electrode implantations; have user friendly human computer interfaces, have versatility towards future applications and be reasonably cost effective. 

A robot is different from a digitally placed machine in that it has a built in computer which makes the calculations necessary to drive the robot from its stand by position, to its target position according to internal logic and “ knowledge “ which we could call its intelligence. The brain’s highly  functional structure calls for precision, restriction of surgical approaches and minimal invasiveness. Robotized approaches are therefore particularly suitable. Robots do not replace the surgeon but assist in repetitive, fastidious and otherwise error prone calculations, to provide reports on images or atlas maps or to perform very precise movements which require stability, precision or long lasting immobility  that even the most skilled surgical hands cannot accomplish. The fragility of the brain parenchyma, its susceptibility to retraction and pressure and the high functionality of its constituents validate such an approach. The steadily decreasing costs of computers, their increasing power, availability of specialized workstations with image processing software and the widespread communication facilities make robotic surgery a possible proposition in selected centers.  

Role of computers in  a Neurocritical care unit:

In a Neurological Critical Care Unit  large volumes of data must be stored, processed and used for quick and repeated clinical decision making.  Effective communication is vital in a NCCU.  Networking with different departments ensures availability of lab data on a real time basis. Indecipherable handwriting will be a thing of  the past.  Using a modem and a PC the neurosurgeon can make effective rounds from his bedroom.  In a difficult case, instantaneous clarification can be obtained from a specialist in another continent, transmitting all the data. Computer systems normally wait till a request is made.  If requested, the therapeutic aspects of various antibiotics - the specific bacteria it covers, relative effectiveness, complications cost etc will all be displayed.  Yet it cannot countermand an order for a drug that is totally inappropriate or even dangerous.  Tomorrows computer with artificial intelligence in the form of neural networking, will be programmed to respond in  different ways.  A nurse in the CCU will require a computer generated order before the physicians order is implemented.  The computer will take into account every known parameter, for the given patient while evaluating the physicians orders.  A warning message will come on the screen -" Please check dose again" and the reasons will be displayed including the relevant citations. Systems which intercept orders BEFORE they can be executed are now available in several centers.  For example an investigation which is not standard, for the work up of a particular condition will not be transmitted to the radiology department. An extensively used programme called HELP ( Health Evaluation through Logical Processing) has been proved to be effective not only in making a diagnosis, but also in alerting the physician to avoidable problems.  Treatment suggestions are also given. An integrated " Medical information Bus " is on the anvil. Linked to 255 devices, this network will intercommunicate in 73 seconds. 

A programme called MEDITEL was tried in the pediatric ICU.  The age, sex, symptoms,  signs and a host of other information requested by the computer was fed in.  The  computer would then give a differential diagnosis with an uncertainty factor.  Though accuracy was only 70 to 90% it was found that with a computer assisted diagnosis there was a trend towards shorter hospital stay, decreased use of consultants and less number of costly tests.  Algorithms for Computer Assisted Diagnosis involves break points that represent all or none decision points.  There is no room for "may be " or " rarely”  However  ingenious programmes using Bayesian logic are now available which can give differential weightage to  a complex array of coexisting symptoms and signs. This can even include  " perhaps " and " maybe ".  In one such application on 331 patients with proved myocardial infarction, experienced physicians made the correct   diagnosis in 79% of cases while the computer got it right in 92 % of cases. Several similar applications will be available in the field of neurological sciences. 

Neural prosthesis:  

In the days of yore, preachers of the gospel claimed that one day the son of God would descend from the heavens. The blind would then see, the deaf would hear, the dumb would talk and the crippled would walk ! Neural prosthesis may make this a possibility. Ultrathin chips placed surgically at the back of the eye could work in conjunction with a miniature camera to stimulate the optic nerves. The camera would fit into a pair of eyeglasses ; a laser attached to the camera would both power the chip and send it visual information via an infrared beam . The microchip would then excite the retinal nerve endings just like healthy cells, simulating some sort of crude vision. Today cochlear implants are even available in India. Voice synthesizers will help the  speechless talk. Patient controlled highly selective deep brain stimulation of  precise nuclei in the brain through implanted electrodes is now possible even in India. Though  expensive this highly sophisticated computer assisted  technology has proved  to be  a boon in the management of Parkinsonism .

Virtual reality in medicine:  

Virtual reality in surgical education will soon be routine reducing complications. The surgeons level of efficiency can be monitored. Since surgery is a series of tasks and each task is a series of steps it may be possible to use " fuzzy logic " and even quantify surgical competence. VR simulators are increasingly becoming more complex. The  " Green  Telepresence Surgery system " consists of  a surgical workstation and a remote worksite. At the remote site there is a 3D camera system and responsive manipulators with sensory input. At the workstation there is a 3D monitor with dexterous handles with force feedback. The VR surgical simulator is a stylized recreation of the human abdomen with several essential organs. Using a helmet mounted display and data glove a person can learn anatomy from a new perspective by " flying " inside and around the organs. Surgical procedures can be practised with a scalpel and clamp. Innovative virtual reality techniques are now being used for quicker rehabilitation of physically disabled patients.  Worlds previously non existent can now be " explored " by the handicapped. The hospital of the future will be first designed and tested in virtual reality, bringing together the full power of the digital physician and his colleague in computer sciences. Prototypes are already in use in neurosciences departments. 

Telemedicine:

As applied to neurological sciences, telemedicine will   be commonplace. Commercial scanners and common telephone lines will suffice. With costs of digital cameras, modems and computers  plummeting, with increasing availability of ISDN lines remote neurological examination will be a reality. Recently in a trial demonstration, the author based in Madras carried out a neurological examination of an individual in Toronto. A paper from Hong Kong, reviewed the use of teleradiology in   transferring neurosurgical patients from a district hospital to a tertiary neurosurgical centre . Unnecessary transfers were reduced  and  more therapeutic measures introduced before transfer. Transfer time was shortened and adverse events during transfer significantly reduced. 

Ireland with a population of 3.5 million has only two neurosurgical centres ( located in Cork and Dublin ). Decision to transfer a patient to these centres were traditionally  based on telephone conversations resulting in significant delays in diagnosis and transfer. With CT scanners being installed in peripheral hospitals a national emergency teleconsultation system was introduced in Ireland. Tertiary consultation depends on the speed, quality and completeness of information   exchanged.  Simple scanners were found effective in delivering high quality images.. A myriad of technical problems were  bypassed by simply printing the films and redigitising them. With the phenomenal  advances in telecommunications, and l availability of ISDN lines, such systems would be cost effective and practical even in India. It is  possible to  transmit through commercial telephone lines,  high  resolution  CT, MRI films, histology slides or even  an   operative field seen under the operating microscope. One can thus obtain instantaneous  advise  from a senior experienced person,  on what is  to  be  done next. 

Internet and Neurosciences:    

Neuroscientists  like other professionals will soon be divided into two groups - Internet literate and Internet illiterate and woe to the latter. A wealth of information on neurology topics is available on websites created and operated by over a hundred and fifty major universities, medical colleges and research centers. There are already more than 100 electronic medical journals.

If a doctor cannot point, click and drag he/ she will soon fade into oblivion. Today in a few seconds an article can be sent to  an " E- journal ", Theoretically the article can be peer reviewed, modified and placed on a global electronic bulletin board within a few hours. The impact of an article can precisely be determined - the number of times it was read, number of times quoted and so on. Big Brother is indeed watching  and how ! On the Internet electronic publishing for a million readers will cost no more than for a single reader. Having hypertext links to reference articles in other electronic journals is much more convenient, than finding the reference number in the bibliography and walking to the library, only to find that particular issue unavailable.