Surgical Planning Purposes Research Articles

Mapping interictal discharges using intracranial EEG-fMRI to predict postsurgical outcomes.

Various subjective and objective methods have been proposed to identify which interictal epileptiform discharge (IED)-related EEG-fMRI results are more likely to delineate seizure generating tissue in patients with drug-resistant focal epilepsy for the purposes of surgical planning. In this intracranial EEG-fMRI study, we evaluated the utility of these methods to localize clinically relevant regions pre-operatively and compared the extent of resection of these areas to post-operative outcome. Seventy patients admitted for intracranial video-EEG monitoring were recruited for a simultaneous intracranial EEG-fMRI study. For all analyses of blood oxygen level-dependent responses associated with IEDs, an experienced epileptologist identified the most Clinically Relevant brain activation cluster using available clinical information. The Maximum cluster (the cluster with the highest z-score) was also identified for all analyses and assigned to one of three confidence levels (low, medium, or high) based on the difference of the peak z-scores between the Maximum and Second Maximum cluster (the cluster with the second highest peak z-value). The distance was measured and compared between the peak voxel of the aforementioned clusters and the electrode contacts where the interictal discharge and seizure onset were recorded. In patients who subsequently underwent epilepsy surgery, the spatial concordance between the aforementioned clusters and the area of resection was determined and compared to post-operative outcome. We evaluated 106 different IEDs in 70 patients. Both subjective (identification of the Clinically Relevant cluster) and objective (Maximum cluster much more significant than the second maximum cluster) methods of culling non-localizing EEG-fMRI activation maps increased the spatial concordance between these clusters and the corresponding IED or seizure onset zone contacts. However, only the objective methods of identifying medium and high confidence maps resulted in a significant association between resection of the peak voxel of the Maximum cluster and post-operative outcome. Resection of this area was associated with good post-operative outcomes but was not sufficient for seizure freedom. On the other hand, we found that failure to resect the medium and high confidence Maximum clusters was associated with a poor post-surgical outcome (negative predictive value = 1.0, sensitivity = 1.0). Objective methods to identify higher confidence EEG-fMRI results are needed to localize areas necessary for good post-operative outcomes. However, resection of the peak voxel within higher confidence Maximum clusters is not sufficient for good outcomes. Conversely, failure to resect the peak voxel in these clusters is associated with a poor post-surgical outcome.

The Creation of an Average 3D Model of the Human Cartilaginous Nasal Septum and Its Biomimetic Applications.

The cartilaginous nasal septum is integral to the overall structure of the nose. Developing our an-atomic understanding of the septum will improve the planning and techniques of septal surgeries. While the basic dimensions of the septum have previously been described, the average shape in the sagittal plane has yet to be established. Furthermore, determining the average shape allows for the creation of a mean three-dimensional (3D) septum model. To better understand the average septal shape, we dissected septums from 40 fresh human cadavers. Thickness was measured across pre-defined points on each specimen. Image processing in Photoshop was used to superimpose lateral photographs of the septums to determine the average shape. The average shape was then combined with thickness data to develop a 3D model. This model may be utilized in finite elemental analyses, creating theoretical results about septal properties that are more translatable to real-world clinical practice. Our 3D septum also has numerous applications for 3D printing. Realistic models can be created for educational or surgical planning purposes. In the future, our model could also serve as the basis for 3D-printed scaffolds to aid in tissue regeneration to reconstruct septal defects. The model can be viewed at the NIH 3D model repository (3DPX ID: 020598, Title: 3D Nasal Septum).

Current and Emerging Trends in Medical Image Segmentation With Deep Learning

In recent years, the segmentation of anatomical or pathological structures using deep learning has experienced a widespread interest in medical image analysis. Remarkably successful performance has been reported in many imaging modalities and for a variety of clinical contexts to support clinicians in computer-assisted diagnosis, therapy or surgical planning purposes. However, despite the increasing amount of medical image segmentation challenges, there remains little consensus on which methodology perform best. Therefore, we examine in this paper the numerous developments and breakthroughs brought since the rise of U-Net inspired architectures. Especially, we focus on the technical challenges and emerging trends that the community is now focusing on, including conditional generative adversarial and cascaded networks, medical Transformers, contrastive learning, knowledge distillation, active learning, prior knowledge embedding, cross-modality learning, multi-structure analysis, federated learning or semi-supervised and self-supervised paradigms. We also suggest possible avenues to be further investigated in future research efforts.

Correlation of Magnetic Resonance Imaging (Neurography) and Electrodiagnostic Study Findings with Intraoperative Findings in Post Traumatic Brachial Plexus Palsy.

Background The majority of brachial plexus injuries (BPIs) are caused by trauma; most commonly due to two-wheeler road accidents. It is important to determine whether the lesion in question is pre-ganglionic or post-ganglionic for purposes of surgical planning and prognosis. Diagnostic testing helps the surgeon to not only decide whether surgical intervention is required, but also in planning the procedure, thereby maximizing the patient's chances of early return to function. The aim of the study was to determine the diagnostic efficacy of electrodiagnostic studies (Edx) and magnetic resonance imaging (MRI) individually, and in unison, in detecting the type and site of BPI by comparison with intraoperative findings (which were used as the reference standard) in patients with posttraumatic BPI. Methods It is an observational cross-sectional prospective randomized study, wherein 48 patients with BPI underwent a detailed clinical and neurological examination of the upper limb, Edx, MRI neurography and were subsequently operated upon. We assessed a total of 240 roots. The diagnosis of all spinal roots was noted on Edx. MRI was performed to look for root avulsion, pseudomeningocoele, and/or rupture injury. The patients were subsequently operated upon. All roots were traced from infraclavicular level right up to the foramen to ensure continuity of root or note rupture/ avulsion. The findings were tabulated. Results MRI accurately diagnosed 138 of the 147 injured roots and MRI sensitivity for the detection of BPI was 93.88%, whereas Edx correctly identified 146 out of 147 injured roots and thus, had sensitivity of 99.32%; however, both lacked specificity (18.28 and 20.43%, respectively). With Edx and MRI in unison, sensitivity was 100% which meant that if a given patient with a BPI is subjected to both tests, not a single abnormal root will go unnoticed. Conclusion Edx and MRI are two highly sensitive investigation modalities whose combined sensitivity is 100% for the detection of a root injury. Therefore, we recommend both tests as they are excellent screening tests.

Anatomical variations and accessory structures in the maxilla in relation to implantological procedures: an observational retrospective study of 212 cases using cone-bean computed tomography

PurposeThis study used cone-beam computed tomography (CBCT) to analyze the prevalence of several maxillary anatomical/accessory structures, as well as variations within each type, assessing how accurate diagnosis can minimize the risk of intraoperative complications during implantological procedures in the oral cavity.Methods212 CBCT scans of the maxilla were analyzed, captured over a period of 18 months for surgical planning purposes. The prevalence of posterior superior alveolar arteries (PSAA), maxillary sinus septa (MSS), and branches of the canalis sinuosus (CS) were evaluated, as were the diameter and location of each anatomical structure in horizontal and vertical planes. P < 0.05 was considered statistically significant.ResultsPSAAs were observed in 99.1% of cases, the intrasinus type being the most frequent; MSS were noted in 15.6% of the sample, mainly in the posterior region with sagittal orientation; CS branches were observed in 50% of patients, mainly in relation to the incisors and significantly more prevalent among males.ConclusionsThe use of CBCT significantly increases the possibility of clearly identifying these anatomical structures. The differences found between patients highlight the importance of carrying out an exhaustive radiological study of the individual to prevent complications, such as Schneiderian membrane perforation, neurovascular damage or bleeding during surgery.Graphical

Surgeon-performed ultrasound changes surgical management in patients with thyroid cancer.

A comprehensive neck ultrasound (US) is essential in the operative planning of patients with thyroid disease. Recent literature has shown surgeon-performed US (SUS) can be more accurate than radiology-performed US for the purpose of surgical planning. Missed findings on radiology-performed ultrasound may lead to inadequate surgical management. A retrospective cohort study of patients undergoing total thyroidectomy with lateral neck dissection for thyroid cancer, with both radiology-performed US and SUS performed by a Head and Neck surgeon. Ultrasound findings and adherence to American Thyroid Association (ATA) guidelines were compared, and changes in management based on SUS findings were identified. A total of 26 patients who underwent total thyroidectomy with lateral neck dissection met the inclusion criteria. Preconsultation US investigations fulfilled criteria as recommended by the American Thyroid Association (ATA) guidelines in 57.7%% of cases. The central and lateral neck compartments were assessed in 57.7% and 84.6% of preconsultation US investigations respectively. Central and lateral metastatic neck metastases were incorrectly reported or not reported in 78.6% and 42.3% of cases. The SUS findings prompted a change in surgical management in 65.4% of cases. SUS changed surgical management in two thirds (65.4%) of patients. Reliance on radiology-performed ultrasound alone may result in incorrect staging. Awareness of the additional benefits of SUS is important for surgeons treating patients with thyroid disease to prevent inadequate surgery being performed.

CT can identify characteristic features of hypaxial muscle abscesses in dogs due to presumed migrating vegetal foreign material as well as additional changes along the migratory tract in other anatomic regions.

Hypaxial muscle abscess is an important differential in dogs presenting for abdominal or back pain, lameness, and nonspecific signs like fever, lethargy, and hyporexia. It can occur concurrently with intrathoracic disease such as pyothorax secondary to migrating vegetal foreign material. Twelve dogs that underwent CT of the lumbar spine or abdomen and had a diagnosed hypaxial abscess on surgical and/or microbiological examination were included in this retrospective, descriptive case series. Computed tomography findings and findings from other imaging modalities employed were described. Eleven dogs were hunting breeds. Clinical signs included lethargy, fever, increased respiratory effort, and abdominal or back pain. Radiography and/or ultrasonography were employed during preliminary work up at clinician discretion and respectively revealed changes consistent with osteomyelitis in the cranial lumbar vertebrae and heterogenous, hypoechoic areas in the hypaxial musculature consistent with abscesses. Computed tomography findings included enlargement of hypaxial muscles with well-defined fluid attenuating noncontrast enhancing areas with a contrast-enhancing rim consistent with abscesses, periosteal reaction and lysis of vertebrae, and retroperitoneal effusion. Four of the 12 cases in this series had material identified and removed at surgery. The other eight cases were presumed to be the same disease process based on compatible signalment, imaging findings, and microbiological results. Migrating vegetal foreign bodies are a common problem at the authors' institution. Computed tomography provided expedient, thorough visualization of the relevant hypaxial lesions for diagnostic and surgical planning purposes and also characterized intrathoracic components of this disease.

Future Directions in Patellofemoral Imaging and 3D Modeling.

Patellofemoral instability involves complex, three-dimensional pathological anatomy. However, current clinical evaluation and diagnosis relies on attempting to capture the pathology through numerous two-dimensional measurements. This current review focuses on recent advancements in patellofemoral imaging and three-dimensional modeling. Several studies have demonstrated the utility of dynamic imaging modalities. Specifically, radiographic patellar tracking correlates with symptomatic instability, and quadriceps activation and weightbearing alter patellar kinematics. Further advancements include the study of three-dimensional models. Automation of commonly utilized measurements such as tibial tubercle-trochlear groove (TT-TG) distance has the potential to resolve issues with inter-rater reliability and fluctuation with knee flexion or tibial rotation. Future directions include development of robust computational models (e.g., finite element analysis) capable of incorporating patient-specific data for surgical planning purposes. While several studies have utilized novel dynamic imaging and modeling techniques to enhance our understanding of patellofemoral joint mechanics, these methods have yet to find a definitive clinical utility. Further investigation is required to develop practical implementation into clinical workflow.

A Unique Cause Of Sciatica In A Masters Martial Arts Athlete

HX 71-year-old male masters martial arts athlete referred for suspected “sciatica.” He had around one month of right buttocks pain with radiation to his posterior thigh. He endorsed a recent increase in his Krav Maga martial arts activity. He had pain localized over the ischial tuberosity, rated an 8/10, and described as sharp and burning. Symptoms provoked with hip movement and weight activities. He endorsed hamstring weakness and had developed a limp while walking. Denied any lower extremity numbness or low back pain. On further questioning of his personal musculoskeletal history, he did admit to a prior right proximal hamstring injury around 1 year, and a remote history of low back pain requiring a L4-L5 decompression surgery. PHYSICAL EXAM: On inspection, he had a soft tissue defect over his ischial tuberosity, but no swelling or ecchymosis. He had an antalgic gait on his right hip, extreme tenderness along his ischial tuberosity and proximal hamstring. Hip range of motion was difficult to assess due to pain. He had 5/5 strength and intact sensation throughout his bilateral lower extremities except for right knee flexion which was 4/5 and painful. Reflexes were 1+ and symmetric at the bilateral knee and ankle. Special testing was negative for a seated slump test bilateral. DIFFERENTIAL: 1. Sciatica 2. Herniated disc 3. Piriformis syndrome TEST/RESULTS: Diagnostic ultrasound of his right posterior hip region was performed in clinic. This demonstrated a high grade retracted and avulsed partial tear of the proximal hamstring tendon, involving both the conjoint and semimembranosus tendons. DIAGNOSIS: Avulsed Proximal Hamstring tear TREATMENT/ OUTCOMES: A right hip MRI was performed for surgical planning purposes. This further demonstrated a high-grade, greater than 75%, partial thickness tear involving the conjoint and semimembranosus tendon origin with 4.4 cm of retraction. He underwent an open proximal primary repair of the hamstring tendon with neuroplasty of the sciatic nerve. The patient began post-operative physical therapy around 1 month after surgery which he successfully completed. 8 months post-operative he has had near resolution of his right buttocks pain at the ischial tuberosity and his posterior thigh pain had resolved. For activity, he has been able to resume cardiovascular exercise with walking and biking.

Prevalence of negative sliding sign representing pouch of Douglas obliteration during pelvic transvaginal ultrasound for any indication

Pouch of Douglas (POD) obliteration can be predicted with a high degree of certainty and reproducibility using the dynamic transvaginal ultrasound (TVS) sliding-sign technique. So far, studies on POD obliteration prediction have focused on tertiary-care populations with high prevalence of endometriosis; however, POD obliteration may exist in individuals with asymptomatic endometriosis or other conditions. Our primary aim was to determine the prevalence of a negative sliding sign, representing POD obliteration, in a cohort of patients undergoing TVS for any gynecological indication. This was a prospective observational study of consecutive women with an indication for gynecological TVS, conducted at a high-volume ultrasound practice between July and August 2018. Clinical and surgical history, indication for TVS and TVS findings were documented. The prevalence of TVS-confirmed POD obliteration, determined by interpretation of the sliding sign, was calculated for the entire cohort and for the subgroups of women with and without risk factors for endometriosis. High risk for endometriosis was defined as having (1) a TVS referral for endometriosis-like pelvic pain or endometriosis specifically and/or (2) clinical symptoms or signs suggestive of endometriosis. Low risk was defined as the absence of these characteristics. During the study period, 1043 consecutive women underwent TVS. After excluding those who underwent transabdominal ultrasound, had a history of hysterectomy or with missing data, 909 women were analyzed. The prevalence of a negative sliding sign in the entire cohort was 47/909 (5.2%). A negative sliding sign was observed in 22/639 (3.4%) women with a low risk for endometriosis and 25/243 (10.3%) of those with a high risk for endometriosis (difference in proportions, 6.9% (95% CI 2.8-10.9%); P < 0.001). We have demonstrated an overall prevalence of a negative sliding sign, suggesting POD obliteration, of 5.2% (or 1/20) in women seeking TVS for a gynecological indication. The prevalence of negative sliding sign in low-risk women is not negligible (3.4% or 1/29 women). These women are most likely to have asymptomatic endometriosis or another important etiology of POD obliteration. The prevalence of a negative sliding sign is approximately three-times higher in women with signs and/or symptoms of endometriosis (10.3% vs 3.4%). Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Pronation on Weightbearing Radiographs is Not Associated with Pronation Calculated from Weightbearing CT Scans

Category:Bunion; OtherIntroduction/Purpose:In hallux valgus (HV), first metatarsal pronation is increasingly recognized as an important aspect of the deformity. Weightbearing CT (WBCT) scans have allowed investigators to quantify pronation of the first metatarsal. Yamaguchi et al. (J Orthop Sci 2015) proposed that pronation of the first metatarsal can be estimated by looking at the shape of the lateral aspect of the first metatarsal head on weightbearing AP radiographs of the foot, which would provide surgeons with a simple and readily available guide for evaluation of pronation. The purpose of this study was to compare pronation determined from the shape of the lateral head of the first metatarsal on AP weightbearing radiographs in HV patients with pronation calculated from WBCT scans.Methods:Patients were included in this study if they had preoperative (n=22 patients) or 5-month postoperative (n=22 patients) WBCT scans and corresponding weightbearing AP radiographs of the affected foot. Pronation on weightbearing AP radiographs was grouped into four groups 0–9°, 10–19°, 20–30°, and >30° as described by Wagner and Wagner (Foot Ankle Clin 2018) by two independent observers. Pronation of the first metatarsal on WBCT scans was measured using a technique developed by Campbell et al. (Foot Ankle Int 2018), which calculates pronation of the first metatarsal in reference to the second metatarsal using a 3D CAD model, and using the alpha angle as described by Kim et al. (Foot Ankle Int 2015) and was categorized into the same four groups described for the radiographs. Weighted kappa coefficients (k) were used to determine interobserver reliability and agreement between pronation groups on radiographs and WBCT scans. Intraclass correlation coefficients were used to determine reliability of the alpha angle measurements on WBCT scans. After dividing patients into plain radiograph pronation groups, differences in mean WBCT pronation of the first metatarsal was compared using Kruskal-Wallis tests.Results:Agreement between the two observers for preoperative and postoperative pronation on radiographs was moderate (k=.529,P<.001) and fair (k=.382,P=0.001), respectively. Intraclass correlation coefficients for preoperative and postoperative alpha angles were good (ICCs > 0.80, P<.001). Pronation of the first metatarsal on radiographs agreed with pronation on WBCT scans using a CAD method in 7 of 22 cases preoperatively (31.8%) and 8 of 22 cases postoperatively (36.4%). However, statistically, this was represented no agreement by more than chance between preoperative or postoperative pronation on WBCT scans and radiographs (k=.041, P=.774 and k=.059, P=.595, respectively) (Figures 1A-B). Similarly, pronation of the first metatarsal on radiographs did not agree with pronation on WBCT scans using the alpha angle measure either preoperatively or postoperatively (k=.070, P=.474 and k=.063, P=.364, respectively). Preoperatively, in the plain radiograph pronation groups of 10-19° (n=9), 20- 29° (n=11), and >30° (n=2), mean pronation calculated from WBCT scans using a 3D CAD method was 21.1°, 25.2°,and 20.9°, respectively (P=.752), and mean pronation calculated using the alpha angle was 13.2°, 15.8°, and 22.3°, respectively (P=.308).Postoperatively, in the plain radiograph pronation groups of 0-9° (n=9), 10-19° (n=6), and 20-29° (n=7), mean pronation calculated from WBCT scans using a 3D CAD method was 22.3°, 22.5°, and 21.0°, respectively (P=.976), and mean pronation calculated using the alpha angle was 3.1°, 5.7°, and 6.4°, respectively (P=.252).Conclusion:: Pronation of the first metatarsal measured on weightbearing AP radiographs using the lateral first metatarsal head had only fair to moderate interobserver agreement and did not statistically significantly agree with pronation measured on WBCT scans using either a 3D CAD model or the alpha angle. Additionally, mean pronation on WBCT scans did not significantly differ by any magnitude between the plain radiograph pronation groups, which indicates that there was no association between pronation measured on WBCT scans and plain radiographs. These results suggest that surgeons should use caution when trying to derive first metatarsal pronation from AP weightbearing radiographs for surgical planning purposes.

Stimulation Mapping Using Stereoelectroencephalography: Current and Future Directions.

Electrical stimulation mapping (ESM) using stereoelectroencephalography (SEEG) is an essential component in the workup of surgical epilepsy. Since the initial application of ESM in the mid-1960s, it remains unparalleled in defining eloquent brain areas and delimiting seizure foci for the purposes of surgical planning. Here, we briefly review the current state of SEEG stimulation, with a focus on the techniques used for identifying the epileptogenic zone and eloquent cortex. We also summarize clinical data on the efficacy of SEEG stimulation in surgical outcomes and functional mapping. Finally, we briefly highlight future applications of SEEG ESM, including novel functional mapping approaches, identifying rare seizure semiologies, neurophysiologic investigations for understanding cognitive function, and its role in SEEG-guided radiofrequency thermal coagulation.

Deep Q-CapsNet Reinforcement Learning Framework for Intrauterine Cavity Segmentation in TTTS Fetal Surgery Planning.

Fetoscopic laser photocoagulation is the most effective treatment for Twin-to-Twin Transfusion Syndrome, a condition affecting twin pregnancies in which there is a deregulation of blood circulation through the placenta, that can be fatal to both babies. For the purposes of surgical planning, we design the first automatic approach to detect and segment the intrauterine cavity from axial, sagittal and coronal MRI stacks. Our methodology relies on the ability of capsule networks to successfully capture the part-whole interdependency of objects in the scene, particularly for unique class instances (i.e., intrauterine cavity). The presented deep Q-CapsNet reinforcement learning framework is built upon a context-adaptive detection policy to generate a bounding box of the womb. A capsule architecture is subsequently designed to segment (or refine) the whole intrauterine cavity. This network is coupled with a strided nnU-Net feature extractor, which encodes discriminative feature maps to construct strong primary capsules. The method is robustly evaluated with and without the localization stage using 13 performance measures, and directly compared with 15 state-of-the-art deep neural networks trained on 71 singleton and monochorionic twin pregnancies. An average Dice score above 0.91 is achieved for all ablations, revealing the potential of our approach to be used in clinical practice.

Nodal drainage pathways in primary rectal cancer: anatomy of regional and distant nodal spread.

Nodal involvement is a significant prognostic factor in rectal cancer and difficult to assess preoperatively. An understanding of the patterns of nodal spread from different regions of the rectum can assist in this process and is essential for the purposes of surgical planning. In this article we define patterns of spread to mesenteric and pelvic sidewall nodal subgroups and discuss the importance of accurate anatomic localization of nodes for the purposes of staging and surgical planning.

Acquisition of Volumetric Models of Skull Base Anatomy Using Endoscopic Endonasal Approaches: 3D Scanning of Deep Corridors Via Photogrammetry

In this study we aim to evaluate the feasibility of creating volumetric models of highly intricate skull-base anatomy-previously not amenable to volumetric reconstruction-using endoscopic endonasal approaches. Ten human cadaveric heads were dissected through the nasal corridor to expose anterior, middle, and posterior cranial fossi structures and the pterygopalatine and infratemporal fossi. A rigid endoscope with a 30° lens was used to capture the images. Subsequently, a photogrammetry software was used to align, smooth, and texturize the images into a complete 3-dimensional model. An average of 174 photographs were used to construct each model (n= 10). In the end, we achieved high-definition stereoscopic volumetric models of the nasal corridor; paranasal fossae; and anterior, middle and posterior fossae structures that preserved structural integrity. Strategic points of interests were labeled and animated for educational use. Endoscopic volumetric models represent a new way to depict the anatomy of the skull base; their use with 3-dimensional technologies could potentially improve the visuospatial understanding of narrow surgical corridors for education and surgical-planning purposes.

Stereoscopic Images from Computed Tomography Angiograms

To present an adaptation of the anaglyph photography technique to be used with radiological images from computed tomography angiograms, enabling stereoscopic visualization of a patient's individual abnormal vascular anatomy for teaching, case discussion, or surgical planning purposes. Traditional anaglyph procedures with actual objects yield 2 independent photographs, simulating the image perceived by each eye. Production of anaglyphs from angiograms involve 3 basic procedures: volume rendering, image capture, and image fusion. Volume renderings were reconstructed using a free, open-source DICOM (Digital Imaging and Communications in Medicine) reader. Subsequently, the virtual object was positioned to mimic the operator's angle of view, and different perspectives of the reconstructed volume could be obtained through exclusively horizontal rotation. The 2 images were then fused after their color composition was modified so that each eye would perceive only 1 image when using anaglyph glasses. Forty-three angiograms were reviewed for the purpose of this study and a total of 6 examinations were selected for illustration of the technique. Stereoscopic display was possible for all of them and in the 3 types of support tested: computer monitor, tablet, and smartphone screens. Anaglyph display of computed tomography angiograms is an effective and low-cost alternative for the stereoscopic visualization of a patient's individual intracranial vascular anatomy.

Development and validation of 3D printed virtual models for robot-assisted radical prostatectomy and partial nephrectomy: urologists' and patients' perception.

To test the face and content validity of 3D virtual-rendered printed models used before robot-assisted prostate cancer and nephron-sparing surgery. Patients who underwent live surgery during an international urological meeting organized in January 2017 were enrolled. Those with organ-confined prostate cancer underwent robot-assisted radical prostatectomy. Patients with a single renal tumor underwent minimally invasive nephron-sparing surgery. High-resolution (HR) imaging was obtained for all patients. Those with kidney tumors received contrast-enhanced CT scan with angiography; those with prostate cancer underwent mp-MRI. Images in DICOM format were processed by dedicated software. The first step was the rendering of a 3D virtual model. The models were then printed. They were presented during the live surgery of the urological meeting. All the participants and the operated patients were asked to fill a questionnaire about their opinion expressed in Likert scale (1-10) about the use and application of the 3D printed models. 18 patients were enrolled, including 8 undergoing robot-assisted radical prostatectomy and 10 undergoing minimally invasive partial nephrectomy. For each patient, a virtual 3D printed model was created. The attendants rated the utility of printed models in surgical planning, anatomical representation and the role of technology in surgical training as 8/10, 10/10 and 9/10, respectively. All patients reported favorable feedbacks (from 9 to 10/10) about the use of the technology during the case discussion with the surgeon. In our experience, 3D printing technology has been perceived as a useful tool for the purpose of surgical planning, physician education/training and patient counseling. Further researches are expected to increase the level of evidence.

Multimodality imaging in prenatal diagnosis and management of aortic arch anomalies

There is a growing body of knowledge regarding the integration of multiple imaging modalities into the care of fetuses with aortic arch anomalies. This study aims to present our experience and fetal cardiac output data from a cohort of patients with discrete aortic coarctation and aortic arch hypoplasia. Methods/ResultsRetrospective review identified 25 fetuses with discrete aortic coarctation (n=8) or aortic arch hypoplasia (n=17) (with mean gestational age at diagnosis, 27.2weeks; at birth 37.6weeks). Mean combined ventricular output in all fetuses with normal ventriculo-arterial concordance was 383ml/min/kg (median 362) with mean R:L cardiac output ratio of 2.83 (median 2.13). Of 23 neonates with primary surgical arch repair, all 7 with discrete coarctation underwent lateral thoracotomy without re-intervention. Of 16 with arch hypoplasia, 10 underwent primary lateral thoracotomy (3 with re-intervention) and 6 underwent primary sternotomy (1 with re-intervention). Of 2 with mild coarctation without primary repair, one with coexistent severe LV dysfunction underwent stenting and dilatation; the other is followed in the context of transposition of the great arteries status post arterial switch. Pre-op CT and 3D cardiac printing were obtained in 19 neonates. During follow-up, five (20%) had systemic hypertension. ConclusionFetal R:L cardiac output ratio may provide complementary hemodynamic information in prenatal diagnosis of aortic arch anomalies. As expected, characterization of arch conformation remains critical for surgical planning. Pre-operative cardiac CT remains a useful adjunct to delineate arch anatomy for surgical planning purposes but may not reduce re-intervention by itself. Benefit of 3D cardiac printing remains difficult to quantify but has become an invaluable tool for family education. Based on our data, neonates with arch hypoplasia may benefit from midline sternotomy for more extensive surgical exposure and potentially reduced re-intervention rate.

Anterior Overgrowth in Primary Curves, Compensatory Curves and Junctional Segments in Adolescent Idiopathic Scoliosis.

IntroductionAlthough much attention has been given to the global three-dimensional aspect of adolescent idiopathic scoliosis (AIS), the accurate three-dimensional morphology of the primary and compensatory curves, as well as the intervening junctional segments, in the scoliotic spine has not been described before.MethodsA unique series of 77 AIS patients with high-resolution CT scans of the spine, acquired for surgical planning purposes, were included and compared to 22 healthy controls. Non-idiopathic curves were excluded. Endplate segmentation and local longitudinal axis in endplate plane enabled semi-automatic geometric analysis of the complete three-dimensional morphology of the spine, taking inter-vertebral rotation, intra-vertebral torsion and coronal and sagittal tilt into account. Intraclass correlation coefficients for interobserver reliability were 0.98–1.00. Coronal deviation, axial rotation and the exact length discrepancies in the reconstructed sagittal plane, as defined per vertebra and disc, were analyzed for each primary and compensatory curve as well as for the junctional segments in-between.ResultsThe anterior-posterior difference of spinal length, based on “true” anterior and posterior points on endplates, was +3.8% for thoracic and +9.4% for (thoraco)lumbar curves, while the junctional segments were almost straight. This differed significantly from control group thoracic kyphosis (-4.1%; P<0.001) and lumbar lordosis (+7.8%; P<0.001). For all primary as well as compensatory curves, we observed linear correlations between the coronal Cobb angle, axial rotation and the anterior-posterior length difference (r≥0.729 for thoracic curves; r≥0.485 for (thoraco)lumbar curves).ConclusionsExcess anterior length of the spine in AIS has been described as a generalized growth disturbance, causing relative anterior spinal overgrowth. This study is the first to demonstrate that this anterior overgrowth is not a generalized phenomenon. It is confined to the primary as well as the compensatory curves, the junctional zones do not exhibit this growth discrepancy, however, they are straight.

The value of MRI in patients with temporomandibular joint dysfunction: Correlation of MRI and clinical findings

AimTo estimate the correlation between the MRI findings and clinical outcomes in patients with temporomandibular joint dysfunction (TMD). Methods and materialsWe included 546 female and 248 male patients who were clinically diagnosed with TMD (mean age 38.7 years) and examined by MRI (T1 and T2 weighted images, parasagittal and paracoronal slices). A questionnaire, radiological, and clinical findings were analysed for statistically significant correlations. The analysed parameters included gender, age, disk position, joint degeneration, arthralgia, mouth opening, condyle position and clinical progress. ResultsOf all TMJ’s 62% showed physiological disc position, 35% anterior and 3% posterior disc position. Modification of therapy occurred in 20% and alteration of diagnosis was found in 32% of all cases. Anterior disc displacement with reduction showed a specificity of 88% and a sensitivity of 78%, whereas anterior disc displacement without reduction showed a specificity of 84% and a sensitivity of 73%. A significant correlation between disc length, condyle morphology and disc displacement was found. With the increase of intra-articular liquid as seen on MRI the level of arthralgia significantly rose as opposed to mouth opening. ConclusionSpecificity and sensitivity, for anterior disc displacement and osseous changes in TMJ were highly acceptable. Results had confirmed the diagnostic capability of MRI in diagnostic imaging of TMJ. Additionally MRI should be used primarily in severe, therapy-resistant cases and for surgical planning purposes.