Senior Neurosurgeon Research Articles

Rapid Ventricular Pacing for Clipping of Intracranial Aneurysms: A Single-centre Retrospective Case Series.

Multiple strategies exist to facilitate microdissection and obliteration of intracranial aneurysms during microsurgical clipping. Rapid ventricular pacing (RVP) can be used to induce controlled transient hypotension to facilitate aneurysm manipulation. We report the indications and outcomes of intraoperative RVP for clipping of ruptured and unruptured complex aneurysms. We completed a retrospective review of adult patients who underwent RVP-facilitated elective and emergent microsurgical aneurysm clipping by a single senior neurosurgeon between 2016 and 2023. Intraoperative RVP was performed at a rate of 150 to 200 beats per minute through a transvenous pacing wire and repeated as needed based on surgical requirements. Intraoperative procedural and pacing data and perioperative cardiac and neurosurgical variables were collected. Forty patients were included in this study. The median (interquartile range) number of pacing episodes per patient was 8 (5 to 14), resulting in a median mean arterial pressure of 37 (30 to 40) mm Hg during RVP. One patient developed wide complex tachycardia intraoperatively, which resolved after cardioversion. Fifteen out of 36 (42%) patients who had postoperative troponin measurements had at least one troponin value above the 99th percentile upper reference limit. One patient had markedly elevated troponin with anterolateral ischemia in the context of massive postoperative intracranial hemorrhage. There were no other documented intraoperative or postoperative cardiac events. This retrospective case series suggests that RVP could be an effective adjunct for clipping of complex ruptured and unruptured aneurysms, associated with transient troponin rise but rare postoperative cardiac complications.

Three scans are better than two for follow-up: An automatic method for finding missed and misidentified lesions in cross-sectional follow-up of oncology patients

PurposeMissed and misidentified neoplastic lesions in longitudinal studies of oncology patients are pervasive and may affect the evaluation of the disease status. Two newly identified patterns of lesion changes, lone lesions and non-consecutive lesion changes, may help radiologists to detect these lesions. This study evaluated a new interpretation revision workflow of lesion annotations in three or more consecutive scans based on these suspicious patterns. MethodsThe interpretation revision workflow was evaluated on manual and computed lesion annotations in longitudinal oncology patient studies. For the manual revision, a senior radiologist and a senior neurosurgeon (the readers) manually annotated the lesions in each scan and later revised their annotations to identify missed and misidentified lesions with the workflow using the automatically detected patterns. For the computerized revision, lesion annotations were first computed with a previously trained nnU-Net and were then automatically revised with an AI-based method that automates the workflow readers’ decisions. The evaluation included 67 patient studies with 2295 metastatic lesions in lung (19 patients, 83 CT scans, 1178 lesions), liver (18 patients, 77 CECT scans, 800 lesions) and brain (30 patients, 102 T1W-Gad MRI scans, 317 lesions). ResultsRevision of the manual lesion annotations revealed 120 missed lesions and 20 misidentified lesions in 31 out of 67 (46%) studies. The automatic revision reduced the number of computed missed lesions by 55 and computed misidentified lesions by 164 in 51 out of 67 (76%) studies. ConclusionAutomatic analysis of three or more consecutive volumetric scans helps find missed and misidentified lesions and may improve the evaluation of temporal changes of oncological lesions.

Aimée Redondo, the First Female Neurosurgeon Professor in France

It is crucial to promote the role of women in surgery, particularly in the field of neurosurgery, which is still predominantly male-dominated. Without recognition and support, these talented and pioneering women may continue to be overlooked, despite their significant contributions to the field. One such remarkable woman is Professor Aimée Redondo, the first female neurosurgeon professor in France. She was born in 1944 during the last years of World War II to immigrant parents from Spain. Thanks to grants and scholarships from the French government, Aimée Redondo was able to continue her education. She excelled in high school and even passed the entrance exam for medical school on her first attempt - a rare achievement at the time. In 1975, at the young age of 31, she became the first female professor of neurosurgery in France. After completing her residency, she worked as a senior neurosurgeon at the Salpêtrière Hospital in Paris and then joined the newly established department of neurosurgery at Beaujon Hospital. For over thirty years, she was a crucial member of this department and served as its head from 2004 until her retirement. Sadly, she passed away in 2022 at the age of 78.

Histogram analysis of mono-exponential, bi-exponential and stretched-exponential diffusion-weighted MR imaging in predicting consistency of meningiomas

BackgroundThe consistency of meningiomas is critical to determine surgical planning and has a significant impact on surgical outcomes. Our aim was to compare mono-exponential, bi-exponential and stretched exponential MR diffusion-weighted imaging in predicting the consistency of meningiomas before surgery.MethodsForty-seven consecutive patients with pathologically confirmed meningiomas were prospectively enrolled in this study. Two senior neurosurgeons independently evaluated tumour consistency and classified them into soft and hard groups. A volume of interest was placed on the preoperative MR diffusion images to outline the whole tumour area. Histogram parameters (mean, median, 10th percentile, 90th percentile, kurtosis, skewness) were extracted from 6 different diffusion maps including ADC (DWI), D*, D, f (IVIM), alpha and DDC (SEM). Comparisons between two groups were made using Student’s t-Test or Mann-Whitney U test. Parameters with significant differences between the two groups were included for Receiver operating characteristic analysis. The DeLong test was used to compare AUCs.ResultsDDC, D* and ADC 10th percentile were significantly lower in hard tumours than in soft tumours (P ≤ 0.05). The alpha 90th percentile was significantly higher in hard tumours than in soft tumours (P < 0.02). For all histogram parameters, the alpha 90th percentile yielded the highest AUC of 0.88, with an accuracy of 85.10%. The D* 10th percentile had a relatively higher AUC value, followed by the DDC and ADC 10th percentile. The alpha 90th percentile had a significantly greater AUC value than the ADC 10th percentile (P ≤ 0.05). The D* 10th percentile had a significantly greater AUC value than the ADC 10th percentile and DDC 10th percentile (P ≤ 0.03).ConclusionHistogram parameters of Alpha and D* may serve as better imaging biomarkers to aid in predicting the consistency of meningioma.

Efficacy and Complications of Percutaneous Balloon Compression for Patients With Trigeminal Neuralgia With and Without Concomitant Continuous Pain

BACKGROUND: Percutaneous balloon compression (PBC) has become one of the most common and effective minimally invasive treatments for trigeminal neuralgia (TN). However, the initial and long-term pain outcomes, as well as the complication rates of PBC for patients with TN with concomitant continuous pain (CCP) have yet to be specifically documented. OBJECTIVE: In this clinical study, we aimed to evaluate and compare the results of PBC in treating TN with and without CCP. STUDY DESIGN: Retrospective study. METHODS: This research retrospectively analyzed the pain outcomes and complications of 57 patients with TN with CCP and 118 patients with TN without CCP who had undergone PBC at our institution from January 2019 through June 2022. Procedures were performed by one senior neurosurgeon in a single center. The postdischarge follow-up and the collection of clinical data, including immediate and long-term pain relief, time to recurrence, and complications, were completed through phone contact by an independent neurosurgeon blind to the patients’ information. Then, the results of the 2 groups were compared; demographic and clinical data were evaluated for possible predictive factors for poor pain outcomes. RESULTS: In this study, PBC immediately resulted in complete pain relief in 70.2% of patients with CCP and significant pain relief in 84.2% of patients with CCP. For patients without CCP, the rates were 73.7% for complete pain relief and 85.6% for significant pain relief. After a minimum 6-month follow-up period, the rates decreased to 52.6% for complete pain relief and 73.7% for significant pain relief in patients with CCP, compared to 54.2% and 75.4% in those without CCP. The initial and long-term pain control rates in patients without CCP were slightly higher than those with CCP, but the differences were not statistically significant (P = 0.878, P = 0.968, respectively). The incidences of postoperative complications were similar between patients with and without CCP (21.1% vs 22.0%, P = 0.883), whereas the remission rate of complications in patients with CCP was significantly lower than that in patients without CCP (25.0% vs 69.2%, P = 0.011). A longer symptoms duration and having a history of neurodestructive procedures were predictive factors for poor outcomes following PBC. LIMITATIONS: The study was performed in a single-center. The nature of this research is retrospective instead of prospective and randomized, with the inability to control completely for variables. Additionally, the follow-up duration was not long enough to observe recurrence in some patients. CONCLUSIONS: This is the first specifically reported experience treating TN with CCP with PBC. PBC can result in significant relief of both episodic and constant pain from TN with CCP. Patients with a longer duration of pain and prior neurodestructive procedures have a higher risk of poor outcomes. The presence of CCP is not associated with pain outcomes and should not be considered a contraindication to PBC. KEY WORDS: Percutaneous balloon compression, trigeminal neuralgia, concomitant continuous pain, pain relief, comparison, efficacy, complication, predictive factor

Tumor characteristics guiding selection of channel-based versus open microscopic approaches for resection of atrial intraventricular meningiomas: patient series.

Atrial intraventricular meningiomas (AIMs) are relatively rare and typically deep-seated tumors that can mandate resection. Compared with transsulcal or transcortical open microscopic approaches, port- or channel-based exoscopic approaches have facilitated a less invasive alternative of tumor access and resection. The authors present a case series of seven patients with AIMs who underwent open microscopic versus channel-based exoscopic resection by a senior neurosurgeon at their institution between 2012 and 2022 to understand patient and tumor features that lent themselves to selection of a particular approach. In the patients harboring three AIMs selected for channel-based resection, the average AIM diameter (2.9 vs 5.2 cm) was smaller, the AIMs were deeper from the cortical surface (2.5 vs 1.1 cm), and the patients had a shorter average postoperative length of stay (3.3 vs 5.8 days) compared with the four patients who underwent open resection. Gross-total resection was achieved in all cases. Complications for both groups included transient homonymous hemianopsia and aphasia. No recurrences were identified over the follow-up period. The authors demonstrate that channel-based exoscopic resection is safe and effective for AIMs 3 cm in diameter and over 2 cm deep. This may help guide neurosurgeons in future approach selection based on tumor features, including size/volume, location, and depth from cortical surface.

Assessing the Training in Neurosurgery with the Implementation of VITOM-3D Exoscope: Learning Curve on Experimental Model in Neurosurgical Practice.

(1) Background: Innovation and continuous demand in the field of visual enhancing technologies and video streaming have led to the discovery of new systems capable of improving visualization and illumination of the surgical field. The exoscope was brought into neurosurgical routine, and nearly ten years later, modern 3D systems have been introduced and tested, giving encouraging results. (2) Methods: In order to evaluate the surgeon's confidence with the exoscope and their increasing ability in terms of time spent and quality of the final achievement since their first encounter with the technique, an experimental trial on 18 neurosurgeons from a single Institution was performed to evaluate the learning curve for the use of the VITOM-3D exoscope in neurosurgical practice on a model of brain and dura mater. (3) Results: A significant improvement in the quality of the performance, number of errors made, and reduction in the time was found after the third iteration of the task, by when almost all the participants felt more comfortable and confident. No significant differences between senior neurosurgeons and resident neurosurgeons were reported. (4) Conclusions: Our results show that three iterations are enough to gain confidence with the exoscope from its first use, regardless of previous experience and training with an operating microscope.

Integrating navigation assistance for redirecting freehanded spinal instrumentation: experience and technique

Retrospective review of all spinal fusions > 3 levels involving the thoracolumbar and/or sacroiliac at a single institution, by a single surgeon between 3/12/2020 and 8/13/2021 were reviewed. All screws that were secondarily navigated after identified as misdirected on intraoperative CT scan were included. Neuromonitoring reports were culled for mA threshold to triggered EMG response for all redirected screws. Intraoperative, post-de novo screw placement images (fluoroscopy scout and intraoperative CT) and post-redirection intraoperative scoliosis films and post-operative scoliosis films were independently reviewed by a senior neuroradiologist. Fifty redirected screws in the thoracic, lumbar, sacral, and ilium were identified as misdirected and redirected via navigation. The new trajectory of all screws was confirmed satisfactory by independent review between a senior neuroradiologist and neurosurgeon. Four screws could not be verified by post-operative imaging (4/50, 8%). All triggered EMG stimulated > 15 mA. No screws required return to the operating room for revision. No patients experienced a post-operative deficit. Redirection of misdirected thoracolumbar and sacroiliac screws can be performed using intraoperative CT and navigation as a means to detect and directly visualize appropriate placement.

Neuroendoscopic Lavage and Third Ventriculostomy for the Treatment of Intraventricular Hemorrhage and Hydrocephalus in Neonates. A Prospective Study with 18 Months of Follow-Up.

Neonatal intraventricular hemorrhage (IVH) may evolve into posthemorrhagic hydrocephalus and cause neurodevelopmental impairment, becoming a common complication of premature infants, occurring in up to 40% of preterm infants weighing less than 1,500 g at birth. Around 10 to 15% of preterm infants develop severe (grades III-IV) IVH. These infants are at high risk of developing posthemorrhagic hydrocephalus. Neuroendoscopic lavage (NEL) is a suitable alternative for the management of this pathology. In this study, an endoscopic surgical approach directed toward the removal of intraventricular hematoma was evaluated for its safety and efficacy. Between August 2016 and December 2019 (29 months), 14 neonates with posthemorrhagic hydrocephalus underwent NEL for removal of intraventricular blood by a single senior neurosurgeon. Complications such as reintervention and ventriculoperitoneal (VP) shunt placement were evaluated prospectively with an 18-month follow-up on average. In total, 14 neonates with IVH grades III and IV were prospectively recruited. Of these, six neonates did not need a VP shunt in the follow-up after neuroendoscopy (group 1), whereas eight neonates underwent a VP shunt placement (group 2). Nonsignificant difference between the groups was found concerning days after neuroendoscopy, clot extraction, third ventriculostomy, lamina terminalis fenestration, and septum pellucidum fenestration. In group 2, there was shunt dysfunction in five cases with shunt replacement in four cases. NEL is a feasible technique to remove intraventricular blood degradation products and residual hematoma in neonates suffering from posthemorrhagic hydrocephalus. In our series, endoscopic third ventriculostomy (ETV) + NEL could be effective in avoiding hydrocephalus after hemorrhage (no control group studied). Furthermore, patients without the necessity of VP-shunt had a better GMFCS in comparison with shunted patients.

Reflections from the Mind of a Senior Neurosurgeon, for Young Neurosurgeons.

Reflections from the Mind of a Senior Neurosurgeon, for Young Neurosurgeons.

Development of a 3D Printed Brain Model with Vasculature for Neurosurgical Procedure Visualisation and Training

Simulation-based techniques using three-dimensional models are gaining popularity in neurosurgical training. Most pre-existing models are expensive, so we felt a need to develop a real-life model using 3D printing technology to train in endoscopic third ventriculostomy. The brain model was made using a 3D-printed resin mold from patient-specific MRI data. The mold was filled with silicone Ecoflex™ 00-10 and mixed with Silc Pig® pigment additives to replicate the color and consistency of brain tissue. The dura mater was made from quick-drying silicone paste admixed with gray dye. The blood vessels were made from a silicone 3D-printed mold based on magnetic resonance imaging. Liquid containing paprika oleoresin dye was used to simulate blood and was pumped through the vessels to simulate pulsatile motion. Seven residents and eight senior neurosurgeons were recruited to test our model. The participants reported that the size and anatomy of the elements were very similar to real structures. The model was helpful for training neuroendoscopic 3D perception and navigation. We developed an endoscopic third ventriculostomy training model using 3D printing technology that provides anatomical precision and a realistic simulation. We hope our model can provide an indispensable tool for young neurosurgeons to gain operative experience without exposing patients to risk.

Comparison of the endoscopic endonasal to microscopic sublabial transsphenoidal approach in a case series of pituitary macroadenomas.

For a number of years, the microscopic sublabial transsphenoidal (MST) approach was considered the gold standard approach for the treatment of pituitary macroadenomas. Nonetheless, the trend is currently shifting away from the MST to the endonasal transsphenoidal (EET) approach. The aim of the present study was to examine the post-operative outcomes of the first cases operated by a team of two young surgeons using the EET approach, compared to the cases operated by a team of senior neurosurgeons with extensive experience with the MST approach. For this purpose, data from 20 patients with pituitary adenoma were retrospectively collected from a single center who were operated by the current and previous pituitary-surgery teams. All the patients who presented with visual impairment in the EET group recovered completely (5/5), whereas 4/5 patients in the MST group recovered completely. Primary hospitalization duration was similar in the two groups. Gross tumor removal was achieved in 90% of patients in the EET group compared to 70% of the patients operated with the MST technique. Intraoperative complications were comparable between the two groups. The first cases operated at the center with EET proved to have better visual outcomes and a larger tumor removal when compared to the MST group. A greater experience in using this technique could exponentiate the differences in the post-operative outcomes, such as a lower hospitalization duration and fewer intraoperative complications. On the whole, colleagues who have yet to familiarize themselves with the EET approach could perhaps be encouraged to learn to utilize this technique, provided that their center is staffed with an experienced team of skull base surgeons to intervene in an intraoperative complication.

Hemorrhage Risk after Stereotactic Radiosurgery for Patients with Unruptured Brain Arteriovenous Malformation: Significance of Vascular Compactness

<h3>Purpose/Objective(s)</h3> Our purpose was to investigate whether the morphology (i.e., compact/ diffuse) of brain arteriovenous malformations (bAVMs) correlates with the incidence of hemorrhagic events in patients with unruptured bAVMs after receiving non-invasive stereotactic radiosurgery (SRS). <h3>Materials/Methods</h3> This study retrospectively included 264 adult patients with unruptured bAVMs undergoing upfront SRS from multi-institutions. Two senior neurosurgeons confirmed the unruptured presentation. The follow-ups were performed in a 6-month interval. Hemorrhagic events were defined as bleeding signs on computed tomography (CT) or magnetic resonance images (MRI). The morphology of bAVMs was evaluated using fully automated segmentation, which calculated the proportion of vessel, brain tissue, and cerebrospinal fluid in bAVMs on T2-weighted MRI. Compactness index, defined as a ratio of vessel to brain tissue, was proposed and further dichotomized based on Youden indices to classify the bAVMs into compact or diffuse type. Cox proportional hazard model was used to identify the independent factors for the occurrence of post-SRS hemorrhage. <h3>Results</h3> The median follow-up duration was 62.1 months. Post-SRS hemorrhage occurred in 14 (5.3%) patients with 2 bAVMs bleeding twice, incurring an annual bleeding risk of 0.9%. Multivariable analysis with stepwise backward variable selection method revealed that bAVM morphology (compact versus diffuse), bAVM volume and prescribed margin dose were significant predictors for post-GKRS hemorrhage. The incidence density of post-GKRS hemorrhage in the compact and diffuse bAVMs were 4.9 and 11.8 (hemorrhagic events/ 1000 person-years (P-Ys)). Among the diffuse bAVMs (n=153), the post-GKRS hemorrhage rate was lower for smaller bAVM volume, <15ml versus 15-30ml versus >30ml (2.2 versus 13.5 versus 26.3 hemorrhagic events/ 1000 P-Ys; p=0.044) and for bAVMs receiving margin dose >16.6 Gy versus <16.6 Gy (5.2 versus 25.8 hemorrhagic events/ 1000 P-Ys; p=0.004). For the compact bAVMs (n=111), the post-GKRS hemorrhage rate was not significantly different between the dose and volume groups. <h3>Conclusion</h3> Compact and smaller bAVMs, with higher prescribed margin dose harbor lower risks of post-SRS hemorrhage. Among the diffuse bAVMs, post-GKRS hemorrhage risk varied with bAVM volume and margin dose. The finding could help guide GKRS treatment decision-making for the unruptured bAVMs.

Assessing the impact of spinal versus general anesthesia on postoperative urinary retention in elective spinal surgery patients

ObjectivePostoperative urinary retention (POUR) is a common and vexing complication in elective spine surgery. Efficacious prevention strategies are still lacking, and existing studies focus primarily on identifying risk factors. Spinal anesthesia has become an attractive alternative to general anesthesia in elective lumbar surgery, with the potential of having a differential impact on POUR. Methods422 spinal anesthesia procedures were prospectively collected between 2017 and 2021 and compared to 416 general anesthesia procedures retrospectively collected between 2014 and 2017, at a single academic center by the same senior neurosurgeon. The main outcome was POUR, defined as the need for straight bladder catheterization or indwelling bladder catheter placement after surgery due to failure to void. A power calculation was performed prior to data collection. ResultsThe general anesthesia group had a higher rate of POUR (9.1 %) compared with the spinal anesthesia group (4.3 %), p = 0.005. At baseline, the spinal anesthesia cohort had an older average age and fewer patients with a history of previous spine surgery. Other comorbid conditions were comparable between the groups. For perioperative characteristics, spinal anesthesia patients had higher ASA scores, shorter operative times, shorter lengths of hospital stay, less operative levels, and zero use of intraoperative bladder catheterization. Acute pain service consult was similar between the groups. A multivariable logistic regression revealed that spinal anesthesia was associated with a significantly lower rate of urinary retention in the spinal anesthesia group (p = 0.0130), after adjusting for potentially confounding factors. Other statistically significant risk factors for POUR included diabetes, (p = 0.003), BPH (p = 0.014), operative time (p = 4.94e-06), and ASA score (p = 0.005). ConclusionsWe collect and analyze one of the largest available cohorts of patients undergoing simple and complex surgeries under spinal and general anesthesia, finding that spinal anesthesia is independently associated with a lower incidence of POUR compared to general anesthesia, even when adjusted for potentially confounding risk factors. Further prospective trials are needed to explore this finding.

Personal experience in intramedullary lesions, in adults

Background: Intramedullary spinal cord lesions (IMSCL) although they are rare, it generates invasion and destruction of the spinal cord. Such lesions must be diagnosed as early as possible, some have histological and genetic aggressiveness, generating severe functional neurological damage.&#x0D; Objective: To identify the optimal strategy for diagnosis and treatment in IMSC, to improve prognosis.&#x0D; Methods: A retrospective clinical study from 2001 to 2021, was performed on 33 adult patients (18 women, 15 men), diagnosed with magnetic resonance imaging with IMSCT. The most common topography was: thoracic 27 cases disposed between T2-T12, cervical 6 cases disposed between C2-C6, lumbar 2 cases at L1-L2. The most frequent symptoms in my cases were: unilateral radicular pain related to the tumour topography or bilateral diffuse burning pain, especially during the night; back and neck stiffness; paresthesia, motor disturbances with an ASIA score of 2-4, and severe atrophy especially in cervical topography, ataxia, initial retention, impotence and later loss of bowel and bladder function with incontinence. All patients were operated by the same senior neurosurgeon with at least 6 months of follow-up postoperatively. For functional outcome, the most important predictors are the preoperative neurological grade, and the high-grade IMSCT generating recurrence and reoperations.&#x0D; Results: The patients addressed the clinic for pain and neurological deficits; the topography of the intramedullary lesion was confirmed by MRI native / with contrast, ultrasonography, and spinal arteriography. Several histologic entities were recorded: ependymomas - 12 cases, astrocytomas - 8 cases, hemangioblastomas - 3 cases, cavernomas - 6 cases, metastases - 2 cases, germ cell tumour - 1 case, malignant peripheral nerve sheath tumour - 1 case. Gross total excision was performed in 25 cases, with no mortality. In eight cases recurrences were recorded requiring the resumption of surgical treatment. In all cases physiotherapy-rehabilitation approach was used, and the outcome was correlated with pre-operatory motor deficits severity, 3 patients with thoracic high-grade astrocytoma underwent stereotactic spine radiosurgery (SSR) with Cyberknife abroad, stopping tumour growth one year after.&#x0D; Conclusions: Intramedullary spinal cord lesions (IMSCL) are rare conditions, and MRI development allows an early diagnosis of these tumours. To adequately counselled patients, with minor preoperative deficits, real expectations concerning the functional outcomes, in benign tumours, and even anatomical healing should be based still on refinements of radical surgical excision. Actual radiotherapy techniques should be used in aggressive tumours.

The role of the pediatric neurosurgeon in abusive head injuries: a survey of members of the International Society for Pediatric Neurosurgery.

Pediatric neurosurgeons are at the forefront of the clinical management of abusive head injuries (AHI) all over the world. However, the discrepancies regarding medical practice and legal requirements in different centers have not been assessed before. We decided to perform an online survey among members of the International Society for Pediatric Neurosurgery (ISPN) regarding their activity, their usual clinical practice regarding the medical and legal management of AHI, and their involvement in judiciary proceedings, research, and prevention campaigns. Ninety members of the ISPN participated in the survey, representing 26% of the registered members. Most responders were senior pediatric neurosurgeons practicing in a university hospital. Their responses show great homogeneity regarding surgical, intensive care, and legal management. We also noted the widespread use of invasive intracranial pressure monitoring and decompressive craniotomy. By contrast, the responses show great disparity regarding the circuit of patients. This disparity may be an obstacle to the collection of data and clinical research, as well as for the involvement of neurosurgeons in multidisciplinary evaluation. A minority of neurosurgeons were engaged in research and actions of prevention. Pediatric neurosurgeons play a pivotal role in the diagnosis and medical management of AHI. Because of their proficiency in head trauma and cerebrospinal fluid disorders, it is desirable that they become more implicated in multidisciplinary meetings, medical expertise, and scientific research, as well as actions of prevention.

High-definition two-dimension video telescope operating monitor-assisted brain and spinal surgery in pediatrics: is it an acceptable substitute for microscopic surgery?

Vision and ergonomics are crucial variables for successful outcomes during neurosurgery procedures. Two-dimension video telescope operating monitor (VITOM) exoscope has emerged as an alternative, which is cheaper than microscope. The aim of this study is to evaluate the clinical utility of 2D VITOM and to compare its merits and demerits with respect to microscope. VITOM 2D (Karl Storz, Germany) was used in 9 cranial and 5 spinal pediatric cases. While KINEVO operative microscope (Carl Zeiss, Germany) was used in 12 cranial and 6 spinal pediatric patients. All surgeries were performed by single senior neurosurgeon. The author's experience and opinions, as well as qualitative data, were analyzed. A comparison was made on image quality, illumination, field of view, and magnification of the operative field and ergonomics. Seven out of 9 cranial pediatric cases were switched from VITOM 2D to operative microscope due to low-image definition in depth of cranial cavity. Poor visualization of bleeding source in surgical field was another major drawback. Two cranial cases in which exoscope were used exclusively, included superficial tumors. In all 5 spinal cases, VITOM 2D was successfully used without any major difficulty. The exoscope's advantages were observed in ergonomics and ease in switching to naked eyes, but the microscope's field of view, illumination, magnification, and user-friendliness was considered superior. 2D-VITOM is best suited for spinal and superficial cranial tumors. However, a lot of modifications are to be done especially in optics to become a substitute for operative microscope.

Virtual-Augmented Reality and Life-Like Neurosurgical Simulator for Training: First Evaluation of a Hands-On Experience for Residents.

BackgroundIn the recent years, growing interest in simulation-based surgical education has led to various practical alternatives for medical training. More recently, courses based on virtual reality (VR) and three-dimensional (3D)-printed models are available. In this paper, a hybrid (virtual and physical) neurosurgical simulator has been validated, equipped with augmented reality (AR) capabilities that can be used repeatedly to increase familiarity and improve the technical skills in human brain anatomy and neurosurgical approaches.MethodsThe neurosurgical simulator used in this study (UpSurgeOn Box, UpSurgeOn Srl, Assago, Milan) combines a virtual component and a physical component with an intermediate step to provide a hybrid solution. A first reported and evaluated practical experience on the anatomical 3D-printed model has been conducted with a total of 30 residents in neurosurgery. The residents had the possibility to choose a specific approach, focus on the correct patient positioning, and go over the chosen approach step-by-step, interacting with the model through AR application. Next, each practical surgical step on the 3D model was timed and qualitatively evaluated by 3 senior neurosurgeons. Quality and usability-grade surveys were filled out by participants.ResultsMore than 89% of the residents assessed that the application and the AR simulator were very helpful in improving the orientation skills during neurosurgical approaches. Indeed, 89.3% of participants found brain and skull anatomy highly realistic during their tasks. Moreover, workshop exercises were considered useful in increasing the competency and technical skills required in the operating room by 85.8 and 84.7% of residents, respectively. Data collected confirmed that the anatomical model and its application were intuitive, well-integrated, and easy to use.ConclusionThe hybrid AR and 3D-printed neurosurgical simulator could be a valid tool for neurosurgical training, capable of enhancing personal technical skills and competence. In addition, it could be easy to imagine how patient safety would increase and healthcare costs would be reduced, even if more studies are needed to investigate these aspects. The integration of simulators for training in neurosurgery as preparatory steps for the operating room should be recommended and further investigated given their huge potential.

Challenges Encountered in Surgical Traumatic Brain Injury Research: A Need for Methodological Improvement of Future Studies

Investigating neurosurgical interventions for traumatic brain injury (TBI) involves complex methodological and practical challenges. In the present report, we have provided an overview of the current state of neurosurgical TBI research and discussed the key challenges and possible solutions. The content of our report was based on an extensive literature review and personal knowledge and expert opinions of senior neurosurgeon researchers and epidemiologists. Current best practice research strategies include randomized controlled trials (RCTs) and comparative effectiveness research. The performance of RCTs has been complicated by the heterogeneity of TBI patient populations with the associated sample size requirements, the traditional eminence-based neurosurgical culture, inadequate research budgets, and the often acutely life-threatening setting of severe TBI. Statistical corrections can mitigate the effects of heterogeneity, and increasing awareness of clinical equipoise and informed consent alternatives can improve trial efficiency. The substantial confounding by indication, which limits the interpretability of observational research, can be circumvented by using an instrumental variable analysis. Traditional TBI outcome measures remain relevant but do not adequately capture the subtleties of well-being, suggesting a need for multidimensional approaches to outcome assessments. In settings in which traditional RCTs are difficult to conduct and substantial confounding by indication can be present, observational studies using an instrumental variable analysis and "pragmatic" RCTs are promising alternatives. Embedding TBI research into standard clinical practice should be more frequently considered but will require fundamental modifications to the current health care system. Finally, multimodality outcome assessment will be key to improving future surgical and nonsurgical TBI research.

Analysis of Myelomalacia and Posterior Longitudinal Ligament Ossification as Prognostic Factors in Patients with Cervical Spondylotic Myelopathy Submitted to Laminoplasty

Abstract Background Cervical spondylotic myelopathy is a degenerative disease of the intervertebral disc and the vertebral body of the spine that causes cervical spinal cord injury due to central vertebral canal stenosis. Its prevalence is higher in the elderly. Treatment is usually surgical when the spinal cord is affected either clinically with pyramidal release or radiologically with the altered spinal cord. Objective The goal of the present study is to analyze the myelomalacia and the ossification of the posterior longitudinal ligament as prognostic factors in the postoperative evolution of patients with cervical canal compression who underwent laminoplasty with the open- or French-door techniques. Methods We performed a retrospective analysis of 18 surgical cases of spondylotic cervical myelopathy of the same senior neurosurgeon, using the chi-squared test to analyze prognostic factors for patients' postoperative evolution in the Nurick scale, after open-door or French-door laminoplasty. Findings The comparison between the pre and postoperative showed an improvement of 71.43% in cases that did not have ligament ossification compared with 45.45% of cases that presented posterior longitudinal ligament ossification. Also, there was a better prognosis in patients without myelomalacia, as 71.43% of them improved their condition against only 45.45% of improvement in those with myelomalacia. Conclusion There is a need for further studies with larger samples to expressively prove that the presence of longitudinal ligament ossification and the previous presence of myelomalacia are factors that can lead to worse prognosis in the postoperative evolution of patients with cervical spondylotic myelopathy submitted to laminoplasty.