Neurosurgical Skills Research Articles

Expanding Neurosurgical Care in Northwest Tanzania: The Early Experience of an Initiative to Teach Neurosurgery at Bugando Medical Centre

Tanzania suffers from a severe lack of health practitioners trained in neurosurgical procedures. To address this problem, we have implemented an initiative, modeled after the experience of other pioneers in international neurosurgery, to establish cost-effective and sustainable neurosurgical care by teaching fundamental neurosurgical skills to local surgeons. In this report we describe our early experience in Northwest Tanzania and discuss the potential for this training model to improve neurosurgical care to a region in need. Between September 2009 and October 2010, three residents and two attendings from our institution spent a total of 15 weeks at Bugando Medical Centre in Mwanza, Tanzania. During this time, we focused on teaching neurosurgical techniques, intraoperative decision-making, and clinical management skills to two local surgeons. The emphasis of our presence was on teaching and providing sustainable neurosurgical care. During this period, we performed 41 neurosurgical procedures with one of two local surgeons. The most common procedures performed were ventriculoperitoneal shunts (22%), myelomeningocele repairs (22%), and cranial trauma cases (17%). Five (12%) cases required the placement of spinal instrumentation. Thirty-nine (95%) patients remained stable or improved at discharge. There were 2 (5%) perioperative deaths. Although numerous challenges remain, our experience demonstrates the potential of this teaching model in providing sustainable neurosurgical care in Northwest Tanzania.

Can Neurosurgical Skills Be Enhanced with Mental Rehearsal?

ical dexterity 66 for surgical Simulation is increasingly being touted as a me enhance skills and accelerate progress on learning significant attention has been paid to developing computer models for surgical simulation, less atte focused on a very economical form of simulation tice.Mental practice, defined as the “mental repetit the absence of actual physical movement,” has be as an effective means of improving skills in sports Positive results have been reported in the fields o skating, tennis, golf, basketball, and triathlons ( has been deemed so effective that many Olympic t letes use it systematically (4). Although mental pra shown to enhance gross and fine motor skills sign cussion about mental practice is essentially absent literature. In the February 2011 issue of the Annals o et al. (1) attempt for the first time to systematical positive effects of mentation on surgical perform domized controlled trial with step-by-step validati Twenty novice surgeons who had not previously laparoscopic surgeries were recruited. They were g ative course on the “theory of laparoscopy,” follow line assessment test of their surgical skills. Th trained to adequate proficiency using a validated laparoscopy course. Participants were then equal using the “closed envelope” technique between a m (MP) group and a control group. to safely es. While sical and has been ntal pracf a task in cognized usic (5). mnastics, entation and athhas been ntly, dise surgical ery, Arora lidate the in a ran-

The Evolution of Future Directions of Neuroendovascular Therapy: From Clips to Coils to ?

L ike many specialties, vascular neurosurgery has evolved over the past several decades, and the nature of the discipline continues to change. This subspecialty of neurological surgery has survived and flourished because of its ability to reinvent itself in the normal process of evolution and scientific advancement. Vascular neurosurgery is a field that should be disease, not procedure, oriented. The environment illustrated in Figure 1 is one that we are familiar and comfortable with, in terms of microsurgical technology, tools, and procedures. Added to our current armamentarium is the utility of intraoperative angiography. However, the scene illustrated in Figure 2 is an extension of the operating room; it is essentially neurosurgical care delivered in a critical care environment in its own right, with dedicated neuroanesthesia and neurophysiologic monitoring, suitable for treatment of complex intracranial revascularization, aneurysm, and arteriovenous malformation therapies. The question arises, What tools and skills are necessary for a complete neurovascular surgeon? Certainly, they involve the microsurgical skills of the cerebrovascular physician and surgeon such as basic neurosurgical skills and a working knowledge of critical care medicine. Complete knowledge of medical therapy of ischemic and hemorrhagic disease is an absolute necessity if we are to be considered stroke specialists not only in the surgical arena but also in the medical arena. However, vascular neurosurgery at present requires additional tools and skills beyond the traditional ones listed above. Vascular neurosurgery can now be described as extraluminal and endoluminal. The extraluminal approach, or open cranial microsurgical technique, involves the use and knowledge of the aneurysm clip and bipolar cautery. Cortical mapping still has its role in arteriovenous malformation resection and/or cavernous malformation resection. The endoluminal approach requires mastery of the microcatheter, coils, balloon systems, liquid embolic materials, and stent technology. Finally, stereotactic neurosurgery/stereotactic radiosurgery has become an integral part for the treatment of certain select cerebral arteriovenous malformations.

Pre-hospital determinants of outcome in traumatic brain injury: Experiences from first comprehensive integrated pre-hospital care providers in India: GVK — EMRI Experience

Indian studies have reported that nearly 1.5 to 2 million persons are injured and 1 million succumb to death every year in India due to traumatic brain injury. Road traffic injuries are the leading cause (60%) of TBIs followed by falls (20%-25%) and violence (10%).It is also a known fact that the best facilities, equipment and skill sets in terms of emergency room, ICU facilities, neurosurgical skills and equipment cannot reverse damage sustained at scene of injury or enroute to hospital. Airway obstruction and aspiration are major cause of death in treatable head injuries. The aims of prevention of secondary brain injury can be met with only in pre-hospital settings. All these facts underscore the need for an efficient pre-hospital care management of head injuries. However, in India, till 2005, no comprehensive data has been available on this aspect of management, because there was no integrated comprehensive pre-hospital care providing service available. In 2005, Emergency Management and Research Institute (EMRI) was established, to take a lead role in providing pre-hospital care. We wish to share our experience and the findings in pre hospital management of Traumatic Brain Injuries(TBI).This is retrospective study of 1607 cases of traumatic brain injury handled by EMRI, in the state of Andhra Pradesh, from 01 Jan 08 to 31 Dec 08. Data captured on patient case report forms (PCR) for this segment of emergencies was reviewed. We studied various components of the data having a bearing on outcome, namely the social, demographic, clinical determinants, response times and outcome.The demographic determinants reveal that incidence of head injury in men is more than twice that in women. It is the people in prime of their age (21–45) who are affected most. The share of victims handled by EMRI shows a preponderance of economically deprived population amongst victims. Analysis of different risk factors revealed that systolic BP at scene and at hospital is significantly correlated with outcome. Paired sample T-test showing a 2-tailed significance of P<0.01at 95 % CI: 3.717–8.777, with T value of 4.843. GCS analysis revealed significant correlation with outcome at level of p<0.01, with Pearson's ‘R’ value of .071. Age of victim showed significant correlation at p<0.05 level with Pearson's R value of.087. SPO2 showed significant correlation with outcome with a significance at level of p < 0.01, and Pearson's ‘R’ value of 0.217. The mean response time was found to be statistically significant at p<0.05 level and a ‘Pearson's R’ value of .094. One way Anova studies showed distance to be significant at P< 0.05 level at 95 % CI: 16.56–43.35, with a f value of 4.376.It is evident from the study that the analysis of risk factors leading to establishing guidelines and protocols for pre hospital management of head injuries can definitely contribute to improving outcomes in TBI.

Neurosciences intensive care medicine in initial neurosurgical training

The authors describe a novel 4-month clinical placement in neurosciences intensive care medicine (NICM) undertaken in the first specialty registrar (ST1) year of neurosurgical training as part of a clinical neurosciences themed training year. Neurosurgery is unique among British surgical specialties in having pioneered themed early years in run-through training to replace basic surgical training in general surgical specialties as part of Modernising Medical Careers. After describing events leading to the new neurosurgical training, the knowledge, skills and attitudes acquired in NICM are highlighted alongside discussion of logistic aspects and future directions from an inaugural experience.

American influence on the origins of neurosurgery in the Netherlands

Although the Netherlands played a major role in the revival of craniotomy in the late 19th century, modern neurosurgery made a late start there. Unlike the situation in other European countries, Dutch neurosurgery lacked a protagonist when, at the turn of the last century, craniotomy became less popular due to discouraging results. During two lecture tours in the US in the 1920s and 1930s, the influential Dutch neurologist Bernard Brouwer also visited the leading neurosurgical centers. He was deeply impressed by the high standards and results in the New World, and upon his return to Amsterdam, he decided to try to change the dismal state of Dutch neurosurgery. Funds were raised to send the general surgeon Ignaz Oljenick for training to Harvey Cushing, and close ties between Amsterdam and neuroscientists in the US remained. Several American neurosurgeons received part of their basic training in Amsterdam. A second Dutch surgeon, Ferdinand Verbeek, honed his neurosurgical skills under Dr. Walter Dandy. The strong American influence on the philosophy and everyday actions of Dutch neurosurgeons continues until this day.

VIRTUAL REALITY IN NEUROSURGICAL EDUCATION

Mastery of the neurosurgical skill set involves many hours of supervised intraoperative training. Convergence of political, economic, and social forces has limited neurosurgical resident operative exposure. There is need to develop realistic neurosurgical simulations that reproduce the operative experience, unrestricted by time and patient safety constraints. Computer-based, virtual reality platforms offer just such a possibility. The combination of virtual reality with dynamic, three-dimensional stereoscopic visualization, and haptic feedback technologies makes realistic procedural simulation possible. Most neurosurgical procedures can be conceptualized and segmented into critical task components, which can be simulated independently or in conjunction with other modules to recreate the experience of a complex neurosurgical procedure. We use the ImmersiveTouch (ImmersiveTouch, Inc., Chicago, IL) virtual reality platform, developed at the University of Illinois at Chicago, to simulate the task of ventriculostomy catheter placement as a proof-of-concept. Computed tomographic data are used to create a virtual anatomic volume. Haptic feedback offers simulated resistance and relaxation with passage of a virtual three-dimensional ventriculostomy catheter through the brain parenchyma into the ventricle. A dynamic three-dimensional graphical interface renders changing visual perspective as the user's head moves. The simulation platform was found to have realistic visual, tactile, and handling characteristics, as assessed by neurosurgical faculty, residents, and medical students. We have developed a realistic, haptics-based virtual reality simulator for neurosurgical education. Our first module recreates a critical component of the ventriculostomy placement task. This approach to task simulation can be assembled in a modular manner to reproduce entire neurosurgical procedures.

Commentary

BACKGROUND The modern management of penetrating head injuries is generally considered a neurosurgical specialty that relies heavily on the use of sequential imaging techniques, an ever-changing armamentarium of sophisticated antibiotics and specific neurosurgical operative skills. Unfortunately these optimal therapeutic components are frequently not available to patients injured in underdeveloped countries. METHODS An unusual case of a young patient suffering a penetrating brain wound and undergoing delayed treatment in an African mission hospital is reviewed. RESULTS A functional but neurologically impaired outcome resulted from limited surgical debridement and short-term broad-spectrum antibiotic administration. CONCLUSIONS The multiple exigencies of surgical practice in an underdeveloped African nation do not preclude successful management of penetrating head trauma.

Weapons of mass destruction and the role of the neurosurgeon

The desire to assist in a crisis should be tempered by a serious assessment of the technical preparation one has undertaken. Additionally, in the same way that a needs assessment is undertaken before prescribing a course of treatment, one should evaluate the actual staffing requirements of the situation. Many physician volunteers were turned away after the World Trade Center attacks because the overwhelming response of available medical personnel quickly exceeded the requirement. Finally, the duration and intensity of preparation should be based on a realistic evaluation of the likelihood of an event occurring that would necessitate use of the training. Before jumping into action in a situation in which weapons of mass destruction have been used, several issues must be addressed. Prior to the crisis, all professionals, neurosurgeons included, should ask how they can prepare themselves and their communities. During the crisis, neurosurgeons should evaluate their roles based on specialized triage training and experience, personal and equipment decontamination training, and the importance of neurosurgical skills. Finally, one should continually ask if there is anything he/she should be doing during the crisis in addition to performing neurosurgical tasks.

The integration of pediatric neurosurgery into the Danish health care system.

In Denmark the neurosurgical speciality comprises the investigation, surgical treatment and follow-up of inherited and acquired illnesses and lesions of the skull, brain, brain vessels and coverings, spinal column, spinal cord and peripheral nerves. There are six neurosurgical departments in Denmark, all of which work on an equal basis, having so-called county and country functions, e.g., treating special and rare diseases. The Neurosurgical University Clinic in Copenhagen at Rigshospitalet, is statefounded with special responsibilities within science and teaching. Through new recommendations given by the National Health Organization, a change of tasks is anticipated in 1993-1994 with centralization of some of the rarer diseases. In the pediatric neurosurgical field these include: brain tumors (30 cases per year), meningomyelocele (10 cases per year) and complicated craniofacial diseases (5 cases per year). The criteria for county or country "diagnosis" are listed in the circular of January 1993. It is emphasized that a department must keep and develop its neurosurgical skills and the necessary expertise, that it is responsible for scientific progress in neurosurgery, and that it must assure quality of clinical treatment through quality-control programs. To achieve this, it is necessary to educate young doctors, but how? Have the Danish authorities given pediatric neurosurgery a thought? The official program for the education of a neurosurgeon in Denmark by 1993 is the following: A. Phase 1: Following 18 months of internship, a oneyear introductory residency in a neurosurgical department is provided. What does that include?

Book reviews

Sir Hugh Cairns, in introducing Almeida Lima's book Cerebral Angiography (Oxford University Press, 1949)—the first English textbook on the subject—wrote: “The reader cannot but be impressed at how much was discovered in the early stages in Lisbon, and how little has since been added.” Lima is said to have performed the first (cut-down) carotid angiogram in England in the 1930s during the 3 years that he spent in London acquiring neurosurgical skills from Cairns. However, Lima himself credited Norman Dott, the Edinburgh neurosurgeon, as being the British pioneer.

Primary Hypothyroidism and the Pituitary

The availability of radioimmunoassay procedures for the measurement of thyroid-stimulating hormone (TSH) has simplified the differential diagnosis of primary vs secondary hypothyroidism. An elevation of the serum TSH level points to primary failure of the thyroid gland as the basis of the hypothyroidism. However, primary hypothyroidism may secondarily affect a variety of aspects of pituitary function, so that clinical tests evaluating pituitary hormone secretion may lose their diagnostic value. 1 Impaired secretion of growth hormone, delayed gonadotropin responses to luteinizing hormone-releasing factor, decreased adrenocorticotropic hormone release, and increased basal and stimulated prolactin levels have been reported in primary hypothyroidism. 1 Two additional findings that may be of particular clinical importance are the occurrence of 2 and sellar enlargement, suggesting the presence of a pituitary tumor. 3 The term amenorrhea-galactorrhea syndrome has taken on a new meaning in recent years. Increasingly sophisticated endocrine, radiological, and neurosurgical skills have decreased the