Microvascular Anastomosis Under 3D Exoscope or Endoscope Magnification: A Proof-Of-Concept Study

Background: Extracranial-intracranial bypass is a challenging procedure that requires special microsurgical skills and an operative microscope. The exoscope is a tool for neurosurgical visualization that provides view on a heads-up display similar to an endoscope, but positioned external to the operating field, like a microscope. The authors carried out a proof-of-concept study evaluating the feasibility and effectiveness of performing microvascular bypass using various new exoscopic tools. Methods: We evaluated microsurgical procedures using a three-dimensional (3D) endoscope, hands-free robotic automated positioning two-dimensional (2D) exoscope, and an ocular-free 3D exoscope, including surgical gauze knot tying, surgical glove cutting, placental vessel anastomoses, and rat vessel anastomoses. Image quality, effectiveness, and feasibility of each technique were compared among different visualization tools and to a standard operative microscope. Results: 3D endoscopy produced relatively unsatisfactory resolution imaging. It was shown to be sufficient for knot tying and anastomosis of a placental artery, but was not suitable for anastomosis in rats. The 2D exoscope provided higher resolution imaging, but was not adequate for all maneuvers because of lack of depth perception. The 3D exoscope was shown to be functional to complete all maneuvers because of its depth perception and higher resolution. Conclusion: Depth perception and high resolution at highest magnification are required for microvascular bypass procedures. Execution of standard microanastomosis techniques was unsuccessful using 2D imaging modalities because of depth-perception-related constraints. Microvascular anastomosis is feasible under 3D exoscopic visualization; however, at highest magnification, the depth perception is inferior to that provided by a standard operative microscope, which impedes the procedure

Laminoplasty versus Laminectomy in the Treatment of Primary Spinal Cord Tumors in Adult Patients: A Systematic Review and Meta-analysis of Observational Studies

The present systematic review and meta-analysis was conducted to compare the safety and efficacy of the two approaches for primary spinal cord tumors (PSCTs) in adult patients (laminoplasty [LP] vs. laminectomy [LE]). LE is one of the most common procedures for PSCTs. Despite advantages of LP, it is not yet widely used in the neurosurgical community worldwide. The efficacy of LP vs. LE remains controversial. Adult patients over 18 years of age with PSCT at the level of the cervical, thoracic, and lumbar spine were included in the study. A literature search was performed in MEDLINE via PubMed, EMBASE, The Cochrane Library, and Google Scholar up to December 2021. Operation time, hospital stay, complications, and incidence of postoperative spinal deformity (kyphosis or scoliosis were extracted. A total of seven retrospective observational studies with 540 patients were included. There were no significant differences between LP and LE group in operation time (p=0.25) and complications (p=0.48). The LE group showed larger postoperative spinal deformity rate than the LP group (odds ratio, 0.47; 95% confidence interval [CI], 0.27−0.84; p=0.01). The LP group had a shorter hospital stay (standardized mean differences, −0.68; 95% CI, −1.03 to −0.34; p=0.0001) than the LE group. Both LP and LE have comparable operative times and total complications in the treatment of PSCT. LP was superior to LE in hospital stay and postoperative spinal deformity rate. However, these findings are limited by the very low quality of the available evidence. Randomized controlled trials are needed for further comparison

Дренування рани після тотального ендопротезування кульшового суглоба

Diseases and injuries of the hip joint take a significant place in the structure of orthopaedic pathology. Total hip arthroplasty is the main treatment method of the hip joint osteoarthritis of the III–IV stages and fractures of the femoral neck in the elderly people. Objective: to analyze the effectiveness of the post­operative wound management after total hip arthroplasty without draining. Methods: a group of 140 patients (age — from 45 to 78 years) who underwent total hip arthroplasty in the period from the beginning of 2017 to April 2019 was sampled for this study. Diagnosis: hip joint osteoarthritis of the III–IV stages, aseptic necrosis of the femoral head, rheumatoid arthritis and the femoral neck fracture. The patients were divided into groups: I — the wound was drained, II — the postoperative wound was without drainage. The groups did not differ in age, sex, body mass index and distribution of diagnosis. Results: blood loss during the operation did not differ and was equal in group I — (367.59 ± 16.19) ml, II — (351.6 ± 7.97) ml. The count of erythrocytes was significantly higher in group I, which characterizes less blood loss after surgery. Prior to surgery, ESR and CRP levels did not differ significantly in both groups. After the surgery and at discharge, we noted significantly lower markers of the inflammation in the I group of patients. The maximum intense of the pain according to VAS scale was 5 points for patients of the Ist group and 9 points in the IInd group. Body temperature in patients of the Ist group elevated up to 37.7°C, II — 39.4°C. There were no differences in the timing of postoperative wound healing. Patients were activated for the next day after the surgery. Patients in group I were discharged from the hospital on average of 2 days earlier than group II. Conclusions: in the group of patients without joint draining revealed faster normalization of erythrocytes, CRP and ESR, low intensity of postoperative pain according to VAS, shortened hospital stay.Заболевания и травмы тазобедренного сустава занимают значительное место в структуре ортопедической патологии. Основным методом лечения коксартроза III–IV стадий и переломов шейки бедренной кости у пожилых людей является тотальное эндопротезирование тазобедренного сустава (ТЭТБС). Цель: проанализировать период после ТЭТБС без дренирования раны. Методы: отобрано 140 пациентов (возраст 45–78 лет), которым с начала 2017 по апрель 2019 выполнено ТЭТБС. Диагноз: коксартроз III–IV стадий, асептический некроз головки бедренной кости, ревматоидный артрит, перелом шейки бедренной кости. Пациентов разделили на группы: I — без дренажа, II — послеоперационную рану дренировали. Группы были одинаковыми по показателям возраста, пола, индекса массы тела, распределения нозологий. Результаты: кровопотеря в операционной не отличалась и составляла в группе I (367,59 ± 16,19) мл, II — (351,6 ± 7,97). Количество эритроцитов была значимо больше у пациентов I группы, что соответствует меньшей кровопотере после операции. До операции уровень СОЭ и СРБ достоверно не отличались в обеих группах. После вмешательства и на момент выписки уровень этих маркеров воспаления был существенно меньшим у больных I группы. Максимальные показатели боли по шкале ВАШ в I группе составили 5 баллов, II — 9. Температура тела у пациентов I группы поднималась до отметки 37,7 °С, II — 39,4 °С. Различий в сроках заживления послеоперационной раны не установлено. Активизацию пациентов проводили на следующие сутки после операции. Выписку из стационара пациентов I группы осуществляли в среднем на 2 суток раньше, чем II. Выводы: в группе пациентов без дренирования сустава выявлена более быстрая нормализация показателей эритроцитов крови, СРБ и СОЭ, низкая интенсивность послеоперационной боли по ВАШ, сокращение срока пребывания в стационаре.Захворювання і травми кульшового суглоба займають значне місце в структурі ортопедичної патології. Основним методом лікування коксартрозу III–IV стадій і переломів шийки стегнової кістки в людей похилого віку є тотальне ендопротезування кульшового суглоба (ТЕКС). Мета: проаналізувати період після ТЕКС без дренування рани. Методи: відібрано 140 пацієнтів (вік 45–78 років), яким із початку 2017 по квітень 2019 р. виконано ТЕКС. Діагноз: коксартроз III–IV стадій, асептичний некроз головки стегнової кістки, ревматоїдний артрит, перелом шийки стегнової кістки. Пацієнтів розділили на групи: І — без дренажу, ІІ — післяопераційну рану дренували. Групи були однаковими за показниками віку, статі, індексу маси тіла, розподілу нозологій. Результати: крововтрата в операційній не відрізнялась і дорівнювала в групі І (367,59 ± 16,19) мл, ІІ — (351,6 ± 7,97). Кількість еритроцитів була значуще більшою в пацієнтів І групи, що відповідає меншій крововтраті після операції. До операції рівні ШОЕ і СРБ достовірно не відрізнялися в обох групах. Після втручання та на момент виписки рівень цих маркерів запалення був суттєво меншим у хворих І групи. Максимальні показники болю за шкалою ВАШ у І групі дорівнювали 5 балів, ІІ — 9. Температура тіла в пацієнтів І групи піднімалася до позначки 37,7 °С, ІІ — 39,4 °С. Відмінностей у термінах загоєння післяопераційної рани не встановлено. Активізовано хворих на наступну добу після хірургічного лікування. Пацієнтів І групи виписано зі стаціонару в середньому на 2 доби раніше, ніж ІІ. Висновки: у групі пацієнтів без дренування суглоба виявлено швидшу нормалізацію показників еритроцитів крові, СРБ і ШОЕ, низьку інтенсивність післяопераційного болю за ВАШ, скорочення терміну перебування в стаціонарі

Facet Joint Fixation and Anterior, Direct Lateral, and Transforaminal Lumbar Interbody Fusions for Treatment of Degenerative Lumbar Disc Diseases: Retrospective Cohort Study of a New Minimally Invasive Technique

BACKGROUND: Anterior, direct lateral, and transforaminal lumbar interbody fusions (ALIF, DLIF, and TLIF) are usually combined with posterior fixation to treat degenerative spinal diseases. Outcomes of ALIF, TLIF, or DLIF combined with a new wedge-shaped interfacet cage plate have not been reported. We assessed early clinical outcomes of patients treated with interbody fusion and facet fixation using a titanium wedge-shaped cage plate. METHODS: This retrospective observational cohort study included patients (n = 80) who underwent 1-level interbody fusion and facet joint fixation via ALIF (n = 24) or DLIF (n = 26) with bilateral facet fixation or TLIF with ipsilateral pedicle screws and contralateral facet fixation (n = 30). Duration of surgery, estimated blood loss, pain (visual analog scale), Oswestry Disability Index (ODI) scores, and Macnab score were assessed up to 12 months after surgery. RESULTS: All patients had a significant decrease in pain scores (P \u3c 0.01) and an increase in ODI scores (P \u3c 0.01), without significant differences between treatment groups. Most surgical outcomes were excellent or good (n = 75, 93.8%) with 5 patients (6.2%) having satisfactory outcomes. Within 2 months, all patients returned to their previous work (66, 82.5%) or lighter work (14, 17.5%). Two patients had fusion failure requiring reoperation. CONCLUSIONS: Facet fixation with the wedge-shaped cage plate was associated with minimal soft tissue damage and a low level of postoperative pain. ALIF, DLIF, and TLIF combined with this technique showed good early postoperative clinical and radiologic outcomes. Further studies are needed to assess long-term results and compare them with other fusion methods

Low-Flow and High-Flow Neurosurgical Bypass and Anastomosis Training Models Using Human and Bovine Placental Vessels: A Histological Analysis and Validation Study

Objective: Microvascular anastomosis is a basic neurosurgical technique that should be mastered in the laboratory. Human and bovine placentas have been proposed as convenient surgical practice models; however, the histologic characteristics of these tissues have not been compared with human cerebral vessels, and the models have not been validated as simulation training models. In this study, the authors assessed the construct, face, and content validities of microvascular bypass simulation models that used human and bovine placental vessels. Methods: The characteristics of vessel segments from 30 human and 10 bovine placentas were assessed anatomically and histologically. Microvascular bypasses were performed on the placenta models according to a delineated training module by \ trained\ participants (10 practicing neurosurgeons and 7 residents with microsurgical experience) and \ untrained\ participants (10 medical students and 3 residents without experience). Anastomosis performance and impressions of the model were assessed using the Northwestern Objective Microanastomosis Assessment Tool (NOMAT) scale and a posttraining survey. Results: Human placental arteries were found to approximate the M 2 -M 4 cerebral and superficial temporal arteries, and bovine placental veins were found to approximate the internal carotid and radial arteries. The mean NOMAT performance score was 37.2 ± 7.0 in the untrained group versus 62.7 ± 6.1 in the trained group (p \u3c 0.01; construct validity). A 50% probability of allocation to either group corresponded to 50 NOMAT points. In the posttraining survey, 16 of 17 of the trained participants (94%) scored the model\u27s replication of real bypass surgery as high, and 16 of 17 (94%) scored the difficulty as \ the same\ (face validity). All participants, 30 of 30 (100%), answered positively to questions regarding the ability of the model to improve microsurgical technique (content validity). Conclusions Human placental arteries and bovine placental veins are convenient, anatomically relevant, and beneficial models for microneurosurgical training. Microanastomosis simulation using these models has high face, content, and construct validities. A NOMAT score of more than 50 indicated successful performance of the microanastomosis tasks

MinION rapid sequencing: Review of potential applications in neurosurgery

BACKGROUND: Gene sequencing has played an integral role in the advancement and understanding of disease pathology and treatment. Although historically expensive and time consuming, new sequencing technologies improve our capability to obtain the genetic information in an accurate and timely manner. Within neurosurgery, gene sequencing is routinely used in the diagnosis and treatment of neurosurgical diseases, primarily for brain tumors. This paper reviews nanopore sequencing, an innovation utilized by MinION and outlines its potential use for neurosurgery. METHODS: A literature search was conducted for publications containing the keywords of Oxford MinION, nanopore sequencing, brain tumor, glioma, whole genome sequencing (WGS), epigenomics, molecular neuropathology, and next-generation sequencing (NGS). In total, 64 articles were selected and used for this review. RESULTS: The Oxford MinION nanopore sequencing technology has had successful applications within clinical microbiology, human genome sequencing, and cancer genotyping across multiple specialties. Technical details, methodology, and current use of MinION sequencing are discussed through the prism of potential applications to solve neurosurgery-related scientific and diagnostic questions. The MinION device has proven to provide rapid and accurate reads with longer read lengths when compared with NGS. For applications within neurosurgery, the MinION device is capable of providing critical diagnostic information for central nervous system (CNS) tumors within a single day. CONCLUSIONS: MinION provides rapid and accurate gene sequencing with better affordability and convenience compared with current NGS methods. Widespread success of the MinION nanopore sequencing technology in providing accurate, rapid, and convenient gene sequencing suggests a promising future within research laboratories and to improve care for neurosurgical patients

Intraoperative fluorescence imaging for personalized brain tumor resection: Current state and future directions

Introduction: Fluorescence-guided surgery is one of the rapidly emerging methods of surgical theranostics. In this review, we summarize current fluorescence techniques used in neurosurgical practice for brain tumor patients, as well as future applications of recent laboratory and translational studies.Methods: Review of the literature.Results: A wide spectrum of fluorophores that have been tested for brain surgery is reviewed. Beginning with a fluorescein sodium application in 1948 by Moore, fluorescence guided brain tumor surgery is either routinely applied in some centers or is under active study in clinical trials. Besides the trinity of commonly used drugs (fluorescein sodium, 5-ALA and ICG), less studied fluorescent stains, such as tetracyclines, cancer-selective alkylphosphocholine analogs, cresyl violet, acridine orange, and acriflavine can be used for rapid tumor detection and pathological tissue examination. Other emerging agents such as activity-based probes and targeted molecular probes that can provide biomolecular specificity for surgical visualization and treatment are reviewed. Furthermore, we review available engineering and optical solutions for fluorescent surgical visualization. Instruments for fluorescent-guided surgery are divided into wide-field imaging systems and hand-held probes. Recent advancements in quantitative fluorescence-guided surgery are discussed.Conclusion: We are standing on the doorstep of the era of marker-assisted tumor management. Innovations in the fields of surgical optics, computer image analysis, and molecular bioengineering are advancing fluorescence-guided tumor resection paradigms, leading to cell-level approaches to visualization and resection of brain tumors

Laser application in neurosurgery

BACKGROUND: Technological innovations based on light amplification created by stimulated emission of radiation (LASER) have been used extensively in the field of neurosurgery. METHODS: We reviewed the medical literature to identify current laser-based technological applications for surgical, diagnostic, and therapeutic uses in neurosurgery. RESULTS: Surgical applications of laser technology reported in the literature include percutaneous laser ablation of brain tissue, the use of surgical lasers in open and endoscopic cranial surgeries, laser-assisted microanastomosis, and photodynamic therapy for brain tumors. Laser systems are also used for intervertebral disk degeneration treatment, therapeutic applications of laser energy for transcranial laser therapy and nerve regeneration, and novel diagnostic laser-based technologies (e.g., laser scanning endomicroscopy and Raman spectroscopy) that are used for interrogation of pathological tissue. CONCLUSION: Despite controversy over the use of lasers for treatment, the surgical application of lasers for minimally invasive procedures shows promising results and merits further investigation. Laser-based microscopy imaging devices have been developed and miniaturized to be used intraoperatively for rapid pathological diagnosis. The multitude of ways that lasers are used in neurosurgery and in related neuroclinical situations is a testament to the technological advancements and practicality of laser science

Utilization of intraoperative confocal laser endomicroscopy in brain tumor surgery

Precise identification of tumor margins is of the utmost importance in neuro-oncology. Confocal microscopy is capable of rapid imaging of fresh tissues at cellular resolution and has been miniaturized into handheld probe-based systems suitable for use in the operating room. We aimed to perform a literature review to provide an update on the current status of confocal laser endomicroscopy (CLE) technology for brain tumor surgery. Aside from benchtop confocal microscopes used in ex vivo fashion, there are four CLE systems that have been investigated for potential application in the workflow of brain tumor surgery. Preclinical studies on animal tumor models and clinical studies on human brain tumors have assessed in vivo and ex vivo imaging approaches, suggesting that confocal microscopy holds promise for rapid identification of the characteristic (diagnostic) histological features of tumor and normal brain tissues. However, there are few studies assessing diagnostic accuracy sufficient to provide a definitive determination of the clinical and economical value of CLE in brain tumor surgery. Intraoperative real-time, high-resolution tissue imaging has significant clinical potential in the field of neuro-oncology. CLE is an emerging imaging technology that shows promise for improving brain tumor surgery workflow in in vivo and ex vivo studies. Future clinical studies are necessary to demonstrate clinical and economic benefit of CLE

Quantitative anatomical comparison of the ipsilateral and contralateral interhemispheric transcallosal approaches to the lateral ventricle

OBJECTIVE The best approach to deep-seated lateral and third ventricle lesions is a function of lesion characteristics, location, and relationship to the ventricles. The authors sought to examine and compare angles of attack and surgical freedom of anterior ipsilateral and contralateral interhemispheric transcallosal approaches to the frontal horn of the lateral ventricle using human cadaveric head dissections. Illustrative clinical experiences with a contralateral interhemispheric transcallosal approach and an anterior interhemispheric transcallosal transchoroidal approach are also related. METHODS Five formalin-fixed human cadaveric heads (10 sides) were examined microsurgically. CT and MRI scans obtained before dissection were uploaded and fused into the navigation system. The authors performed contralateral and ipsilateral transcallosal approaches to the lateral ventricle. Using the navigation system, they measured areas of exposure, surgical freedom, angles of attack, and angle of view to the surgical surface. Two clinical cases are described. RESULTS The exposed areas of the ipsilateral (mean [± SD] 313.8 ± 85.0 mm) and contralateral (344 ± 87.73 mm) interhemispheric approaches were not significantly different (p = 0.12). Surgical freedom and vertical angles of attack were significantly larger for the contralateral approach to the most midsuperior reachable point (p = 0.02 and p = 0.01, respectively) and to the posterosuperior (p = 0.02 and p = 0.04) and central (p = 0.04 and p = 0.02) regions of the lateral wall of the lateral ventricle. Surgical freedom and vertical angles of attack to central and anterior points on the floor of the lateral ventricle did not differ significantly with approach. The angle to the surface of the caudate head region was less steep for the contralateral (135.6° ± 15.6°) than for the ipsilateral (152.0° ± 13.6°) approach (p = 0.02). CONCLUSIONS The anterior contralateral interhemispheric transcallosal approach provided a more expansive exposure to the lower two-thirds of the lateral ventricle and striothalamocapsular region. In normal-sized ventricles, the foramen of Monro and the choroidal fissure were better visualized through the lateral ventricle ipsilateral to the craniotomy than through the contralateral approach