The modified retrosigmoid approach: a how I do it

BACKGROUND: The traditional retrosigmoid (RS) approach provides limited exposure of the inferior compartment of the CPA, while radical skull base approaches are demanding and associated with significant morbidity. METHODS: This study outlines the relevant surgical anatomy and the different surgical steps of a modified retrosigmoid (MRS) approach. RESULTS: The MRS provides enhanced exposure of the CPA and deep vascular structures resulting from a modified RS craniotomy and limited exposure of the sigmoid sinus. CONCLUSION: In selected posterior fossa lesions, this cisternal approach is a straightforward corridor that can be routinely performed as a safe alternative to radical cranial base approaches

Toward the development of 3-dimensional virtual-reality video tutorials in the French neurosurgical residency program

BACKGROUND: The present study developed 3D video tutorials with commentaries, using virtual-reality headsets (VRH). VRHs allow 3D visualization of complex anatomy from the surgeon\u27s point of view. Students can view the surgery repeatedly without missing the essential steps, simultaneously receiving advice from a group of experts in the field. METHODS: A single-center prospective study assessed surgical teaching using 3D video tutorials designed for French neurosurgery and ENT residents participating in the neuro-otology lateral skull-base workshop of the French College of Neurosurgery. At the end of the session, students filled out an evaluation form with 5-point Likert scale to assess the teaching and the positive and negative points of this teaching tool. RESULTS: 22 residents in neurosurgery (n=17, 81.0%) and ENT (n=5) were included. 18 felt that the 3D video enhanced their understanding of the surgical approach (81.8 %). 15 (68.2%) thought the video provided good 3D visualization of anatomical structures and 20 that it enabled better understanding of anatomical relationships (90.9%). Most students had positive feelings about ease of use and their experience of the 3D video tutorial (n=14, 63.6%). 20 (90.9%) enjoyed using the video. 12 (54.5%) considered that the cadaver dissection workshop was more instructive. CONCLUSIONS: 3D video via a virtual reality headset is an innovative teaching tool, approved by the students themselves. A future study should evaluate its long-term contribution, so as to determine its role in specialized neurosurgery and ENT diploma courses

History of degenerative spondylolisthesis: From anatomical description to surgical management

This review of the historical medical literature aimed at understanding the evolution of surgical management of degenerative spondylolisthesis over time. The Medic@, IndexCat and Gallica historical databases and PubMed and Embase medical databases were used, with several search-terms, exploring the years 1700-2018. Data from anatomical, biomechanical, pathophysiological and surgical studies were compiled. In total, 150 documents were obtained, dating from 1782 to 2018: 139 from PubMed, 1 from Medic@, 7 from IndexCat, and 3 from Gallica. The review thus ranges in time from (1) description of the first clinical cases by several authors in Europe (1782), (2) the identification of a distinct entity by MacNab (1963), and (3) surgical management by the emerging discipline of minimally invasive spine surgery, to its subsequent evolution up to the present day. Spondylolisthesis is a frequent condition potentially responsible for a variety of functional impairments. Understanding and surgical management have progressed since the 20th century. Historically, the first descriptions of treatments concerned only spondylolisthesis associated with spondylolysis, especially in young adults. More recently, there has been progress in the understanding of the disease in elderly people, with the recognition of degenerative spondylolisthesis. New technologies and surgical techniques, aided by advances in supportive care, now provide spine surgeons with powerful treatment tools. Better knowledge of the evolution of surgery throughout history should enable better understanding of current approaches and concepts for treating degenerative spondylolisthesis

Predictive Factors of Poor Prognosis After Surgical Management of Traumatic Acute Subdural Hematomas: A Single-Center Series

BACKGROUND: Traumatic acute subdural hematomas (ASDHs) showed the highest mortality of intracranial hematomas. The aim of the current study was to identify predictive factors of poor prognosis among patients who were operated on. METHODS: This is a single-center retrospective cohort study of 82 patients who underwent surgical evacuation of a traumatic ASDH between January 2009 and December 2016. The epidemiologic, clinical, radiologic, and surgical features were recorded. Postoperative outcome were assessed by the Glasgow Outcome Scale (GOS) score at 6 months. Univariate and multivariate analysis and a classification and regression tree (CART) were performed. RESULTS: At 6 months, 76% of patients achieved an unfavorable outcome (GOS score 1-3). The context of polytrauma (P = 0.03) and ASDH thickness ≥20 mm (P = 0.02) were significantly associated with poor outcome in the multivariate analysis. The CART algorithm isolated 3 subgroups of patients with an unfavorable prognosis: polytrauma (91%), isolated head injury (HI) featuring an ASDH thickness ≥20 mm (89%), or isolated HI featuring a thickness <20 mm in a patient older than 54 years (71%). Isolated patients with HI younger than 54 years harboring an ASDH <20 mm thick had the most promising results, with 53% with a GOS score of 4 or 5. CONCLUSIONS: The context of polytrauma, ASDH thickness, and age were major predictive factors of poor prognosis in patients with surgically evacuated traumatic ASDH. The CART algorithm using these features isolated subgroups with decreasingly unfavorable outcome, providing a relevant statistical tool to apply to future studies of traumatic ASDH

The Surgeon in Action: Representations of Neurosurgery in Movies from the Frères Lumière to Today

In this review, we examine the portrayal of neurosurgery and neurosurgeons in 61 movies produced from the beginnings of cinema from the Lumière brothers (1895) to 2017, across 4 continents and covering 10 cinematic genres. We find that these movies tend to shape most beliefs and stereotypes about neurosurgery. However, we notice that there is a trend to describe neurosurgery and neurosurgical disorders with more accuracy as we progress in time. Although it is not for the medical profession to dictate or censor fictional content, a keen eye on these depictions will help us to understand, and perhaps combat, some of the stereotypes and myths that continue to surround neurosurgery in the twenty-first century

Stereoscopic Surgical Video of Combined Petrosectomy With Virtual Reality Headset: 3-Dimensional Operative Video

The use of 3-dimensional (3D) videos allows students to visualize surgical procedures from the perspective of the surgeon without missing the essential parts.1 This 3D commented video demonstrates the operative technique and surgical nuances of the combined petrosectomy, visualize using virtual reality headsets. Historically, traditional intradural cisternal routes using suboccipital and pterional approaches have been proposed to remove petroclival tumors.2-5 It allows rapid identification of neurovascular structures and a short exposure time. However, access to the petroclival region is far, not direct, and requires intradural cerebral retraction.6 In order to improve the access for tumoral dissection, lateral transpetrosal approaches have been proposed.7-12 The extradural route shortened the distance to the petroclival region, allows to better preserve the veins, to decrease the cerebral retraction, to interrupt early the tumor vascular supply, and a larger extent of resection.6 Transpetrosal approaches includes middle fossa approach8,10 (removing the petrous apex), posterior petrosal approach9,13,14 (removing of presigmoid retrolabyrinthine bone), and translabyrinthine petrosectomy.12 A combined petrosectomy may be used to approach larger tumor extending across the clival midline, upward to the tentorium or downward to the lower cranial nerves.6,10,15,16 Alternatively, according to Nanda, a retro-sigmoid approach may need to be performed to avoid critical draining veins injury.10,17 Good resection and outcomes are obtained when experienced surgeons use familiar approaches and microsurgical techniques.1

Long term surgical results of 154 petroclival meningiomas: A retrospective multicenter study

BACKGROUND: Outcomes of petroclival meningiomas (PCM) (morbidity, permanent cranial nerves deficit, tumor removal and recurrence) are inconsistent in the literature, making it a challenge to predict surgical morbidity. METHODS: A multicenter study of patients with PCMs larger than 2.5cm between 1984 and 2017 was conducted. The authors retrospectively reviewed the patients\u27 medical records, imaging studies and pathology reports to analyze presentation, surgical approach, neurological outcomes, complications, recurrence rates and predictive factors. RESULTS: There were 154 patients. The follow-up was 76.8 months on average (range 8-380 months). Gross total resection (GTR) was achieved in 40 (26.0%) patients, subtotal resection (STR) in 101 (65.6%), and partial resection in 13 (8.3%). Six (2.6%) perioperative deaths occurred. The 5-year, 10-year and 15-year progression-free survival (PFS) of GTR and STR with radiation therapy (RT) was similar (100%, 90% and 75%). PFS of STR without adjuvant radiation was associated with progression in 71%, 51% and 31%, respectively. Anterior petrosectomy and combined petrosectomy were associated with higher postoperative CN V and CN VI deficits compared to the retrosigmoid approach. The latter had a significantly higher risk of CN VII, CN VIII and LCN deficit. Temporal lobe dysfunction (seizure and aphasia) were significantly associated with the anterior petrosectomy approach. CONCLUSIONS: Our study shows that optimal subtotal resection of PCMs associated with postoperative RT or stereotactic radiosurgery results in long-term tumor control to equivalent radical surgery. Case selection and appropriate intraoperative judgement are required to reduce the morbidity

Record linkage to obtain birth outcomes for the evaluation of screening biomarkers in pregnancy: a feasibility study

<p>Abstract</p> <p>Background</p> <p>Linking population health data to pathology data is a new approach for the evaluation of predictive tests that is potentially more efficient, feasible and efficacious than current methods. Studies evaluating the use of first trimester maternal serum levels as predictors of complications in pregnancy have mostly relied on resource intensive methods such as prospective data collection or retrospective chart review. The aim of this pilot study is to demonstrate that record-linkage between a pathology database and routinely collected population health data sets provides follow-up on patient outcomes that is as effective as more traditional and resource-intensive methods. As a specific example, we evaluate maternal serum levels of PAPP-A and free <it>β</it>-hCG as predictors of adverse pregnancy outcomes, and compare our results with those of prospective studies.</p> <p>Methods</p> <p>Maternal serum levels of PAPP-A and free <it>β</it>-hCG for 1882 women randomly selected from a pathology database in New South Wales (NSW) were linked to routinely collected birth and hospital databases. Crude relative risks were calculated to investigate the association between low levels (multiples of the median ≤ 5^thpercentile) of PAPP-A or free <it>β</it>-hCG and the outcomes of preterm delivery (<37 weeks), small for gestational age (<10^thpercentile), fetal loss and stillbirth.</p> <p>Results</p> <p>Using only full name, sex and date of birth for record linkage, pregnancy outcomes were available for 1681 (89.3%) of women included in the study. Low levels of PAPP-A had a stronger association with adverse pregnancy outcomes than a low level of free <it>β</it>-hCG which is consistent with results in published studies. The relative risk of having a preterm birth with a low maternal serum PAPP-A level was 3.44 (95% CI 1.96–6.10) and a low free <it>β</it>-hCG level was 1.31 (95% CI 0.55–6.16).</p> <p>Conclusion</p> <p>This study provides data to support the use of record linkage for outcome ascertainment in studies evaluating predictive tests. Linkage proportions are likely to increase if more personal identifiers are available. This method of follow-up is a cost-efficient technique and can now be applied to a larger cohort of women.</p

A prevalence survey of every-day activities in pregnancy

<p>Abstract</p> <p>Background</p> <p>Research into the effects of common activities during pregnancy is sparse and often contradictory. To examine whether common activities are an acute trigger of pregnancy complications the prevalence of these activities are necessary to determine sample size estimates. The aim of this study is to ascertain the prevalence of selected activities in any seven day period during pregnancy.</p> <p>Methods</p> <p>The study was conducted in the antenatal clinic of a teaching hospital with tertiary obstetric and neonatal care in Sydney, Australia between August 2008 and April 2009. Women who were at least 20 weeks pregnant and able to read English completed a questionnaire to assess whether they had performed a list of activities in the seven days prior to survey completion. Results were analysed using frequency tabulations, contingency table analyses and chi square tests.</p> <p>Results</p> <p>A total of 766 surveys were completed, 29 surveys were excluded as the women completing them were less than 20 weeks pregnant, while 161 women completed the survey more than once. Ninety seven per cent of women completed the survey when approached for the first time, while 87% completed the survey when approached a subsequent time. In the week prior to completing the survey 82.6% of women had consumed a caffeinated beverage, 42.1% had had sexual intercourse, 32.7% had lifted something over 12 kilograms, 21.4% had consumed alcohol and 6.4% had performed vigorous exercise. The weekly prevalence of heavy lifting was higher for multiparous women compared to nulliparous women.</p> <p>Conclusions</p> <p>The results of this study can be used to inform future research into activities as acute triggers of pregnancy complications.</p