The Changing Environment in Postgraduate Education in Orthopedic Surgery and Neurosurgery and Its Impact on Technology-Driven Targeted Interventional and Surgical Pain Management : Perspectives from Europe, Latin America, Asia, and The United States

Personalized care models are dominating modern medicine. These models are rooted in teaching future physicians the skill set to keep up with innovation. In orthopedic surgery and neurosurgery, education is increasingly influenced by augmented reality, simulation, navigation, robotics, and in some cases, artificial intelligence. The postpandemic learning environment has also changed, emphasizing online learning and skill- and competency-based teaching models incorporating clinical and bench-top research. Attempts to improve work–life balance and minimize physician burnout have led to work-hour restrictions in postgraduate training programs. These restrictions have made it particularly challenging for orthopedic and neurosurgery residents to acquire the knowledge and skill set to meet the requirements for certification. The fast-paced flow of information and the rapid implementation of innovation require higher efficiencies in the modern postgraduate training environment. However, what is taught typically lags several years behind. Examples include minimally invasive tissue-sparing techniques through tubular small-bladed retractor systems, robotic and navigation, endoscopic, patient-specific implants made possible by advances in imaging technology and 3D printing, and regenerative strategies. Currently, the traditional roles of mentee and mentor are being redefined. The future orthopedic surgeons and neurosurgeons involved in personalized surgical pain management will need to be versed in several disciplines ranging from bioengineering, basic research, computer, social and health sciences, clinical study, trial design, public health policy development, and economic accountability. Solutions to the fast-paced innovation cycle in orthopedic surgery and neurosurgery include adaptive learning skills to seize opportunities for innovation with execution and implementation by facilitating translational research and clinical program development across traditional boundaries between clinical and nonclinical specialties. Preparing the future generation of surgeons to have the aptitude to keep up with the rapid technological advances is challenging for postgraduate residency programs and accreditation agencies. However, implementing clinical protocol change when the entrepreneur–investigator surgeon substantiates it with high-grade clinical evidence is at the heart of personalized surgical pain management

Augmented and virtual reality in surgery—the digital surgical environment:applications, limitations and legal pitfalls

The continuing enhancement of the surgical environment in the digital age has led to a number of innovations being highlighted as potential disruptive technologies in the surgical workplace. Augmented reality (AR) and virtual reality (VR) are rapidly becoming increasingly available, accessible and importantly affordable, hence their application into healthcare to enhance the medical use of data is certain. Whether it relates to anatomy, intraoperative surgery, or post-operative rehabilitation, applications are already being investigated for their role in the surgeons armamentarium. Here we provide an introduction to the technology and the potential areas of development in the surgical arena

Augmented Reality in Surgical Navigation: A Review of Evaluation and Validation Metrics

Pre-operative imaging has been used earlier to guide traditional surgical navigation systems. There has been a lot of effort in the last decade to integrate augmented reality into the operating room to help surgeons intra-operatively. An augmented reality (AR) based navigation system provides a clear three-dimensional picture of the interested areas over the patient to aid surgical navigation and operations, which is a promising approach. The goal of this study is to review the application of AR technology in various fields of surgery and how the technology is used for its performance in each field. Assessment of the available AR assisted navigation systems being used for surgery is reviewed in this paper. Furthermore, a discussion about the required evaluation and validation metric for these systems is also presented. The paper comprehensively reviews the literature since the year 2008 for providing relevant information on applying the AR technology for training, planning and surgical navigation. It also describes the limitations which need to be addressed before one can completely rely on this technology for surgery. Thus, additional research is desirable in this emerging field, particularly to evaluate and validate the use of AR technology for surgical navigation. 2023 by the authors.This publication was made possible by NPRP-11S-1219-170106 from the Qatar National Research Fund (a member of Qatar Foundation).Scopu

Current and Future Advances in Surgical Therapy for Pituitary Adenoma

The vital physiological role of the pituitary gland, alongside its proximal critical neurovascular structures means pituitary adenomas cause significant morbidity or mortality. Whilst enormous advancements have been made in the surgical care of pituitary adenomas, treatment failure and recurrence remain challenges. To meet these clinical challenges, there has been an enormous expansion of novel medical technologies (e.g. endoscopy, advanced imaging, artificial intelligence). These innovations have the potential to benefit each step of the patient journey, and ultimately, drive improved outcomes. Earlier and more accurate diagnosis addresses this in part. Analysis of novel patient data sets, such as automated facial analysis or natural language processing of medical records holds potential in achieving an earlier diagnosis. After diagnosis, treatment decision-making and planning will benefit from radiomics and multimodal machine learning models. Surgical safety and effectiveness will be transformed by smart simulation methods for trainees. Next-generation imaging techniques and augmented reality will enhance surgical planning and intraoperative navigation. Similarly, the future armamentarium of pituitary surgeons, including advanced optical devices, smart instruments and surgical robotics, will augment the surgeon's abilities. Intraoperative support to team members will benefit from a surgical data science approach, utilising machine learning analysis of operative videos to improve patient safety and orientate team members to a common workflow. Postoperatively, early detection of individuals at risk of complications and prediction of treatment failure through neural networks of multimodal datasets will support earlier intervention, safer hospital discharge, guide follow-up and adjuvant treatment decisions. Whilst advancements in pituitary surgery hold promise to enhance the quality of care, clinicians must be the gatekeepers of technological translation, ensuring systematic assessment of risk and benefit. In doing so, the synergy between these innovations can be leveraged to drive improved outcomes for patients of the future

Advanced Endoscopic Navigation:Surgical Big Data,Methodology,and Applications

随着科学技术的飞速发展，健康与环境问题日益成为人类面临的最重大问题之一。信息科学、计算机技术、电子工程与生物医学工程等学科的综合应用交叉前沿课题，研究现代工程技术方法，探索肿瘤癌症等疾病早期诊断、治疗和康复手段。本论文综述了计算机辅助微创外科手术导航、多模态医疗大数据、方法论及其临床应用：从引入微创外科手术导航概念出发，介绍了医疗大数据的术前与术中多模态医学成像方法、阐述了先进微创外科手术导航的核心流程包括计算解剖模型、术中实时导航方案、三维可视化方法及交互式软件技术，归纳了各类微创外科手术方法的临床应用。同时，重点讨论了全球各种手术导航技术在临床应用中的优缺点，分析了目前手术导航领域内的最新技术方法。在此基础上，提出了微创外科手术方法正向数字化、个性化、精准化、诊疗一体化、机器人化以及高度智能化的发展趋势。【Abstract】Interventional endoscopy (e.g., bronchoscopy, colonoscopy, laparoscopy, cystoscopy) is a widely performed procedure that involves either diagnosis of suspicious lesions or guidance for minimally invasive surgery in a variety of organs within the body cavity. Endoscopy may also be used to guide the introduction of certain items (e.g., stents) into the body. Endoscopic navigation systems seek to integrate big data with multimodal information (e.g., computed tomography, magnetic resonance images, endoscopic video sequences, ultrasound images, external trackers) relative to the patient's anatomy, control the movement of medical endoscopes and surgical tools, and guide the surgeon's actions during endoscopic interventions. Nevertheless, it remains challenging to realize the next generation of context-aware navigated endoscopy. This review presents a broad survey of various aspects of endoscopic navigation, particularly with respect to the development of endoscopic navigation techniques. First, we investigate big data with multimodal information involved in endoscopic navigation. Next, we focus on numerous methodologies used for endoscopic navigation. We then review different endoscopic procedures in clinical applications. Finally, we discuss novel techniques and promising directions for the development of endoscopic navigation.X.L. acknowledges funding from the Fundamental Research Funds for the Central Universities. T.M.P. acknowledges funding from the Canadian Foundation for Innovation, the Canadian Institutes for Health Research, the National Sciences and Engineering Research Council of Canada, and a grant from Intuitive Surgical Inc

Optimization of craniosynostosis surgery: virtual planning, intraoperative 3D photography and surgical navigation

Mención Internacional en el título de doctorCraniosynostosis is a congenital defect defined as the premature fusion of one or more cranial sutures. This fusion leads to growth restriction and deformation of the cranium, caused by compensatory expansion parallel to the fused sutures. Surgical correction is the preferred treatment in most cases to excise the fused sutures and to normalize cranial shape. Although multiple technological advancements have arisen in the surgical management of craniosynostosis, interventional planning and surgical correction are still highly dependent on the subjective assessment and artistic judgment of craniofacial surgeons. Therefore, there is a high variability in individual surgeon performance and, thus, in the surgical outcomes. The main objective of this thesis was to explore different approaches to improve the surgical management of craniosynostosis by reducing subjectivity in all stages of the process, from the preoperative virtual planning phase to the intraoperative performance. First, we developed a novel framework for automatic planning of craniosynostosis surgery that enables: calculating a patient-specific normative reference shape to target, estimating optimal bone fragments for remodeling, and computing the most appropriate configuration of fragments in order to achieve the desired target cranial shape. Our results showed that automatic plans were accurate and achieved adequate overcorrection with respect to normative morphology. Surgeons’ feedback indicated that the integration of this technology could increase the accuracy and reduce the duration of the preoperative planning phase. Second, we validated the use of hand-held 3D photography for intraoperative evaluation of the surgical outcome. The accuracy of this technology for 3D modeling and morphology quantification was evaluated using computed tomography imaging as gold-standard. Our results demonstrated that 3D photography could be used to perform accurate 3D reconstructions of the anatomy during surgical interventions and to measure morphological metrics to provide feedback to the surgical team. This technology presents a valuable alternative to computed tomography imaging and can be easily integrated into the current surgical workflow to assist during the intervention. Also, we developed an intraoperative navigation system to provide real-time guidance during craniosynostosis surgeries. This system, based on optical tracking, enables to record the positions of remodeled bone fragments and compare them with the target virtual surgical plan. Our navigation system is based on patient-specific surgical guides, which fit into the patient’s anatomy, to perform patient-to-image registration. In addition, our workflow does not rely on patient’s head immobilization or invasive attachment of dynamic reference frames. After testing our system in five craniosynostosis surgeries, our results demonstrated a high navigation accuracy and optimal surgical outcomes in all cases. Furthermore, the use of navigation did not substantially increase the operative time. Finally, we investigated the use of augmented reality technology as an alternative to navigation for surgical guidance in craniosynostosis surgery. We developed an augmented reality application to visualize the virtual surgical plan overlaid on the surgical field, indicating the predefined osteotomy locations and target bone fragment positions. Our results demonstrated that augmented reality provides sub-millimetric accuracy when guiding both osteotomy and remodeling phases during open cranial vault remodeling. Surgeons’ feedback indicated that this technology could be integrated into the current surgical workflow for the treatment of craniosynostosis. To conclude, in this thesis we evaluated multiple technological advancements to improve the surgical management of craniosynostosis. The integration of these developments into the surgical workflow of craniosynostosis will positively impact the surgical outcomes, increase the efficiency of surgical interventions, and reduce the variability between surgeons and institutions.Programa de Doctorado en Ciencia y Tecnología Biomédica por la Universidad Carlos III de MadridPresidente: Norberto Antonio Malpica González.- Secretario: María Arrate Muñoz Barrutia.- Vocal: Tamas Ung

Interactive Visualization of Multimodal Brain Connectivity: Applications in Clinical and Cognitive Neuroscience

Magnetic resonance imaging (MRI) has become a readily available prognostic and diagnostic method, providing invaluable information for the clinical treatment of neurological diseases. Multimodal neuroimaging allows integration of complementary data from various aspects such as functional and anatomical properties; thus, it has the potential to overcome the limitations of each individual modality. Specifically, functional and diffusion MRI are two non-invasive neuroimaging techniques customized to capture brain activity and microstructural properties, respectively. Data from these two modalities is inherently complex, and interactive visualization can assist with data comprehension. The current thesis presents the design, development, and validation of visualization and computation approaches that address the need for integration of brain connectivity from functional and structural domains. Two contexts were considered to develop these approaches: neuroscience exploration and minimally invasive neurosurgical planning. The goal was to provide novel visualization algorithms and gain new insights into big and complex data (e.g., brain networks) by visual analytics. This goal was achieved through three steps: 3D Graphical Collision Detection: One of the primary challenges was the timely rendering of grey matter (GM) regions and white matter (WM) fibers based on their 3D spatial maps. This challenge necessitated pre-scanning those objects to generate a memory array containing their intersections with memory units. This process helped faster retrieval of GM and WM virtual models during the user interactions. Neuroscience Enquiry (MultiXplore): A software interface was developed to display and react to user inputs by means of a connectivity matrix. This matrix displays connectivity information and is capable to accept selections from users and display the relevant ones in 3D anatomical view (with associated anatomical elements). In addition, this package can load multiple matrices from dynamic connectivity methods and annotate brain fibers. Neurosurgical Planning (NeuroPathPlan): A computational method was provided to map the network measures to GM and WM; thus, subject-specific eloquence metric can be derived from related resting state networks and used in objective assessment of cortical and subcortical tissue. This metric was later compared to apriori knowledge based decisions from neurosurgeons. Preliminary results show that eloquence metric has significant similarities with expert decisions

Clinical Application of Three-dimensional Printing and Extended Reality in Congenital Heart Disease

This PhD study investigates the clinical role of the two emerging techniques, which are 3D printing and virtual reality, to improve the visualisation and surgical planning of congenital heart disease. This research findings show that both of these technologies can enhance the users’ perception on the spatial relationship of the heart structures and defects, and therefore improving the management of congenital heart disease

Surgical GPS Proof of Concept for Scoliosis Surgery

Scoliotic deformities may be addressed with either anterior or posterior approaches for scoliosis correction procedures. While typically quite invasive, the impact of these operations may be reduced through the use of computer-assisted surgery. A combination of physician-designated anatomical landmarks and surgical ontologies allows for real-time intraoperative guidance during computer-assisted surgical interventions. Predetermined landmarks are labeled on an identical patient model, which seeks to encompass vertebrae, intervertebral disks, ligaments, and other soft tissues. The inclusion of this anatomy permits the consideration of hypothetical forces that are previously not well characterized in a patient-specific manner. Updated ontologies then suggest procedural directions throughout the surgical corridor, observing the positioning of both the physician and the anatomical landmarks of interest at the present moment. Merging patient-specific models, physician-designated landmarks, and ontologies to produce real-time recommendations magnifies the successful outcome of scoliosis correction through enhanced pre-surgical planning, reduced invasiveness, and shorted recovery time

Optimization of computer-assisted intraoperative guidance for complex oncological procedures

Mención Internacional en el título de doctorThe role of technology inside the operating room is constantly increasing, allowing surgical procedures previously considered impossible or too risky due to their complexity or limited access. These reliable tools have improved surgical efficiency and safety. Cancer treatment is one of the surgical specialties that has benefited most from these techniques due to its high incidence and the accuracy required for tumor resections with conservative approaches and clear margins. However, in many cases, introducing these technologies into surgical scenarios is expensive and entails complex setups that are obtrusive, invasive, and increase the operative time. In this thesis, we proposed convenient, accessible, reliable, and non-invasive solutions for two highly complex regions for tumor resection surgeries: pelvis and head and neck. We explored how the introduction of 3D printing, surgical navigation, and augmented reality in these scenarios provided high intraoperative precision. First, we presented a less invasive setup for osteotomy guidance in pelvic tumor resections based on small patient-specific instruments (PSIs) fabricated with a desktop 3D printer at a low cost. We evaluated their accuracy in a cadaveric study, following a realistic workflow, and obtained similar results to previous studies with more invasive setups. We also identified the ilium as the region more prone to errors. Then, we proposed surgical navigation using these small PSIs for image-to-patient registration. Artificial landmarks included in the PSIs substitute the anatomical landmarks and the bone surface commonly used for this step, which require additional bone exposure and is, therefore, more invasive. We also presented an alternative and more convenient installation of the dynamic reference frame used to track the patient movements in surgical navigation. The reference frame is inserted in a socket included in the PSIs and can be attached and detached without losing precision and simplifying the installation. We validated the setup in a cadaveric study, evaluating the accuracy and finding the optimal PSI configuration in the three most common scenarios for pelvic tumor resection. The results demonstrated high accuracy, where the main source of error was again incorrect placements of PSIs in regular and homogeneous regions such as the ilium. The main limitation of PSIs is the guidance error resulting from incorrect placements. To overcome this issue, we proposed augmented reality as a tool to guide PSI installation in the patient’s bone. We developed an application for smartphones and HoloLens 2 that displays the correct position intraoperatively. We measured the placement errors in a conventional and a realistic phantom, including a silicone layer to simulate tissue. The results demonstrated a significant reduction of errors with augmented reality compared to freehand placement, ensuring an installation of the PSI close to the target area. Finally, we proposed three setups for surgical navigation in palate tumor resections, using optical trackers and augmented reality. The tracking tools for the patient and surgical instruments were fabricated with low-cost desktop 3D printers and designed to provide less invasive setups compared to previous solutions. All setups presented similar results with high accuracy when tested in a 3D-printed patient-specific phantom. They were then validated in the real surgical case, and one of the solutions was applied for intraoperative guidance. Postoperative results demonstrated high navigation accuracy, obtaining optimal surgical outcomes. The proposed solution enabled a conservative surgical approach with a less invasive navigation setup. To conclude, in this thesis we have proposed new setups for intraoperative navigation in two complex surgical scenarios for tumor resection. We analyzed their navigation precision, defining the optimal configurations to ensure accuracy. With this, we have demonstrated that computer-assisted surgery techniques can be integrated into the surgical workflow with accessible and non-invasive setups. These results are a step further towards optimizing the procedures and continue improving surgical outcomes in complex surgical scenarios.Programa de Doctorado en Ciencia y Tecnología Biomédica por la Universidad Carlos III de MadridPresidente: Raúl San José Estépar.- Secretario: Alba González Álvarez.- Vocal: Simon Droui