Orbeye

http://medical.olympusamerica.com/products/orbeye

Olympus, a global technology leader in designing and delivering innovative solutions for medical and surgical procedures, among other core businesses, announced today the launch of its 4K-3D Video Microscope, ORBEYE. The new microscope was developed by Sony Olympus Medical Solutions Inc, (SOMED) a joint venture between Olympus Corporation and Sony Imaging Products & Solutions Inc.

The precise 4K-3D digital images from the new ORBEYE microscope can enable more accurate surgery by providing high-resolution 3D imaging of the structure of tissue, blood vessels and other features. By displaying the progress of surgical procedures on a large 55-inch monitor, the new model has the potential to both reduce surgeon fatigue by eliminating the need for extensive viewing via microscope eyepieces and to include the entire surgical team in the view of the procedure. Because the use of digital technology has made the new microscope unit approximately 95 percent smaller in volume above the surgical field than the previous model, it additionally helps free up surgical space and shortens setup times. The microscope unit was also made 50 percent lighter than the previous model to facilitate its transportation between operating rooms. The device will be marketed by Olympus Corporation.

The benefits of ergonomics, improved precision and ease of positioning in the OR are the result of the following features:

High-resolution 4K-3D digital images supporting precision surgery – The two Sony 4K ExmorRTM CMOS image sensors deliver high-sensitivity, low-noise images. The system deploys an image processing circuit designed to work across a wide color range as well as with four times the pixel count of the Full High Definition standard to provide high-resolution digital images during surgery. Because it additionally minimizes the delay associated with the large amounts of data that need to be processed by 4K-3D systems, ORBEYE provides zero image latency for smoother viewing and manipulation of the target location.

Use of 55-inch 4K 3D monitor helps reduce surgeon fatigue and facilitates team surgery – The new model displays via a monitor and has no eyepiece. This helps reduce surgeon fatigue by allowing a more comfortable working posture without requiring them to spend long periods peering into a microscope lens. Moreover, because the large 55-inch monitor enables the entire surgical team to view the same image, it allows more than one surgeon to operate and improves efficiency by allowing information to be shared with other surgical staff.

Significant reduction in microscope size (95 percent smaller than previous model) helps free up surgical space and shortens setup times – The use of digital technology has made the microscope unit much smaller and it therefore provides the surgeon with additional space to perform operations. The unit’s reduced size also allows faster setup times by eliminating the need to make often awkward adjustments to the balance of the arm, and by allowing use of a smaller and easier-to-fit surgical drape to keep the microscope clean.

“The ORBEYE exoscope represents the next generation of operative imaging- a true quantum shift,” said Dr. David Langer, MD, Lenox Hill Hospital/Northwell Health. “Its adoption is certain and will impact the use of loupe magnification as well as the current operating microscope. The ease of use, surgeon ergonomics and effects upon the operating team are revolutionary and I look forward to continuing to train and develop new strategies for its adoption.”

“We have already received resounding enthusiasm for our 4K and 3D technology for laparoscopy and endoscopy. We are pleased that through the development of ORBEYE, this 4K-3D technology can be offered to more specialties such as neurosurgery, spine, microsurgery, ENT, and cardiac,” said Randy Clark, Group Vice President of the Surgical Division at Olympus America Inc. “We understood that with such complex and lengthy surgeries, the technology would have to be innovative and groundbreaking enough to entice surgeons to make a change, and we were pleased to work with SONY through our SOMED joint venture to meet the challenge.”

The name ORBEYE, a combination of “orb” and “eye”, expresses the idea of being able to approach things from an angle or direction that was not possible using existing microscopes. It also references the product’s potential for global reach.

ORBEYE launched to the healthcare community at the Congress of Neurological Surgeons (CNS) in Boston, October 7-11, 2017.


Murai et al. from Tokyo, reported 22 clinical cases by 5 experienced neurosurgeons and the comparative results of training 10 residents. An observation study with questionnaire survey was conducted on usability. Twelve items including image quality, eyestrain, and function of the arm were evaluated.

The following 22 clinical procedures were conducted: surgery for intracranial hemorrhage (n = 2) and brain tumor (n = 8), laminectomy (n = 3), aneurysm clipping (n = 3), vascular anastomosis (n = 2), carotid endarterectomy (n = 2), and nerve decompression (n = 1). No complications were observed. The fluorescent study, including indocyanine-green and 5-aminolevunic acid, allowed for clear depiction on the 4K monitor. The surgeon could operate in a comfortable posture. Similar to the microscope, it was possible to change the optical and viewing axes with the OE, but the OE was switched to the microscope or endoscope in hematoma removal and pituitary surgeryResidents judged that eyestrain was strong (P = .0096). Experienced neurosurgeons acting as assistants judged that the scope arm’s range of movement was narrow (P = .0204). Sixty percent of residents judged that the OE was superior to the microscope.

Although based on limited experience, it was not possible to substitute the microscope with the OE in all operations; however, the OE surpasses the microscope in terms of ergonomic features 1).

1) Murai Y, Sato S, Yui K, Morimoto D, Ozeki T, Yamaguchi M, Tateyama K, Nozaki T, Tahara S, Yamaguchi F, Morita A. Preliminary Clinical Microneurosurgical Experience With the 4K3-Dimensional Microvideoscope (ORBEYE) System for Microneurological Surgery: Observation Study. Oper Neurosurg (Hagerstown). 2018 Dec 3. doi: 10.1093/ons/opy277. [Epub ahead of print] PubMed PMID: 30508178.

Lipomyelomeningocele

A type of Lipomyeloschisis.

Lipomyelomeningocele, is a closed neural tube defect, taht usually occurs in the lumbosacral area as a single lesion but can be associated with other spinal dysraphism 1) and Caudal regression syndrome.

Represent a unique population within the spectrum of spinal dysraphism.Edit

Pathology

A subcutaneous lipoma that passes through a midline defect in the lumbodorsal fascia, vertebral neural arch, and dura, and merges with an abnormally low tethered cord 2).Edit

Diagnosis

New dynamic MRI-based parameters to establish the presence and magnitude of tethered cord syndrome (TCS) have been defined. oscillatory frequency (OF) measured the extent of loss of translational cord displacement in supine and prone positions; delta bending angle (ΔBA) defined the relative angulation of conus with lower spinal cord, and sagittal and axial root angles represented ventral nerve root stretching. The difference in OF or ΔBA was minimum in the group with thick filum terminale and progressively increased in the groups with lipomyelomeningocele and meningomyelocele 3)Edit

Natural history

The natural history of LMMC remains poorly defined. The description and prevalence of the presenting orthopaedic clinical signs and symptoms for LMMC have been infrequent and often documented only in general terms.Edit

Treatment

Untethering surgery.

An expansile dural graft should be incorporated in cases of lipomyelomeningocele in which primary dural closure does not permit free flow of CSF4).Edit

Case series

In 32 patients with LMMC (21 female and 11 male patients). The majority of patients had their primary tethered cord release (TCR) by ≤1 year of age (59 %), with 22 and 19 % having primary TCR at ages 1-15 and >15 years, respectively. Fifteen patients had at least one repeat TCR, with ten of these having more than one repeat TCR. A significant relationship was noted between low back/radicular pain and repeat TCR (p < 0.001). Ten patients (31%) had a limb length discrepancy of >2.5 cm, and 53 % of patients had asymmetric involvement. Nine patients (28 %) had scoliosis of whom only one required operative treatment. Fifteen patients had foot deformities. Thirteen patients (41 %) had two or more orthopaedic procedures in addition

The presenting musculoskeletal clinical signs and symptoms in patients with LMMC are uniquely different in terms of both pattern and frequency compared to myelomeningocele and other forms of spinal dysraphism.

Its a high prevalence of asymmetrical involvement, a high operative burden, and a high rate of repeat symptomatic tethered cord syndrome requiring TCR. As previously noted by others, TCR in LMMC does not prevent long-term functional deterioration. These findings may be important to our colleagues providing counsel to their patients with LMMC and to their families 5).Edit

Case reports

Fetal lipomyelomeningocele was suspected during the second-trimester ultrasound and confirmed by magnetic resonance imaging. The pregnancy took its course and a term neonate was delivered. At 2 years of age lipomyelomeningocele surgical removal was performed. The patient is now 4 years old and, despite neurogenic bladder, is a healthy boy with normal psychomotor development for his age. This case illustrates the favorable prognosis of this entity and the importance of prompt diagnosis and multidisciplinary counseling 6).Edit

References

Edit1) Hanif H, Khanbabazadeh S, Nejat F, El Khashab M. Tethered cord with tandem lipomyelomeningoceles, split cord malformation and thick filum. J Pediatr Neurosci. 2013 Sep;8(3):204-6. doi: 10.4103/1817-1745.123665. PubMed PMID: 24470813.2) Emery JL, Lendon RG. Lipomas of the Cauda Equina and Other Fatty Tumors Related to Neurospinal Dysraphism.DevMedChildNeurol.1969;11:62–703) Singh S, Behari S, Singh V, Bhaisora KS, Haldar R, Krishna Kumar G, Mishra P, Phadke RV. Dynamic magnetic resonance imaging parameters for objective assessment of the magnitude of tethered cord syndrome in patients with spinal dysraphism. Acta Neurochir (Wien). 2018 Nov 20. doi: 10.1007/s00701-018-3721-7. [Epub ahead of print] PubMed PMID: 30456429.4) Alexiades NG, Ahn ES, Blount JP, Brockmeyer DL, Browd SR, Grant GA, Heuer GG, Hankinson TC, Iskandar BJ, Jea A, Krieger MD, Leonard JR, Limbrick DD Jr, Maher CO, Proctor MR, Sandberg DI, Wellons JC 3rd, Shao B, Feldstein NA, Anderson RCE. Development of best practices to minimize wound complications after complex tethered spinal cord surgery: a modified Delphi study. J Neurosurg Pediatr. 2018 Sep 14:1-9. doi: 10.3171/2018.6.PEDS18243. [Epub ahead of print] PubMed PMID: 30215584.5) Segal LS, Czoch W, Hennrikus WL, Wade Shrader M, Kanev PM. The spectrum of musculoskeletal problems in lipomyelomeningocele. J Child Orthop. 2013 Dec;7(6):513-9. doi: 10.1007/s11832-013-0532-5. Epub 2013 Oct 8. PubMed PMID: 24432115.6) Sarmento-Gonçalves I, Cunha M, Loureiro T, Pinto PS, Ramalho C. Fetal lipomyelomeningocele: A closed neural tube defect diagnosed at second trimester ultrasound examination. J Clin Ultrasound. 2018 Nov 8. doi: 10.1002/jcu.22662. [Epub ahead of print] PubMed PMID: 30411358.

Disc height

Disc degeneration is a normal part of aging, and usually is not a problem. However, Degenerative Disc Disease (DDD) can cause discs to lose height and become stiff. When disc height is lost, nerve impingement, bone and joint inflammation, and resultant pain can occur.

see Disc height index.


Previous studies have demonstrated that the length of the lumbar spine is decreasing with age. Despite considerable research based on sagittal measurements, little is known about the changes in the volume of vertebrae. The objective of a study of Miękisiak et al. from Opole, Lublin, Wrocław, Poland. was to evaluate the changes in the volume of either column of the spine with age.

Computed tomography scans of 62 asymptomatic subjects, performed for thoracolumbar trauma evaluation were used to create virtual 3D models. At least 10 patients were assigned to every decade of life from third to eight. They used a novel technique to measure the volume of anterior column (AC) and posterior column (PC) per each segment (a total of 310 segments). Midline sagittal images were used to measure disc height (DH) and vertebral body height (VH).

With age, both DH increases, whereas the VH decreases. The overall length of lumbar segment of the spine decreases with age. The volumetric measurements performed on same subjects showed that volume of both AC and PC does not change with age in females. In males, there is a weak but statistically significant correlation between AC volume and age and no change in the volume of PC. The ratio of PC:AC volume does not change with age in women, although it decreases slightly but significantly (in favor of AC) with age in males.

The overall length of lumbar spine decreases with age. This process is not a result of mere changes in the volume of either AC or PC 1).


Nerve root compression was evident in twenty-one of the 100 foramina, in eight of the ten foramina in which the posterior disc height was four millimeters or less, and in four of the five foramina in which the foraminal height was fifteen millimeters or less. These critical dimensions may be indicators of lumbar foraminal stenosis. However, compression of a spinal nerve root does not always cause sciatica, and the clinical findings must always be taken into account when a diagnosis of stenosis is considered2).

1) Miękisiak G, Łątka D, Janusz W, Urbański W, Załuski R, Kubaszewski Ł. Thechange of volume of the lumbar vertebrae along with aging in asymptomaticpopulation: a preliminary analysis. Acta Bioeng Biomech. 2018;20(4):25-30. PubMedPMID: 30520452.2) Hasegawa T, An HS, Haughton VM, Nowicki BH. Lumbar foraminal stenosis:critical heights of the intervertebral discs and foramina. A cryomicrotome study in cadavera. J Bone Joint Surg Am. 1995 Jan;77(1):32-8. PubMed PMID: 7822353.

Epithelioid osteoblastoma

Epithelioid “aggressive” osteoblastoma (EOB) is a rare and more aggressive subtype of osteoblastoma (OB) with a higher recurrence rate, greater risk of malignant transformation, larger size, and greater intraoperative blood loss.

The result of statistical analysis suggested that Epithelioid OBL (EO) of the spine with Enneking classification stage 3 (St.3) and total spondylectomy were independent prognostic factors for recurrence-free survival (RFS).

St.3 or EO lesions seem to be more aggressive than St.2 or conventional osteoblastomas, but St.3 and EO should be considered simultaneously in predicting the aggressiveness of the lesion and the risk of recurrence. Total spondylectomy performed either by en bloc or piecemeal could significantly reduce recurrence of OBLs in the mobile spine 1).

Case reports

Attiah et al. from Dr. Cipto Mangunkusumo Hospital published a epithelioid osteoblastoma of the temporal bone in 2018 2).


A 21-year-old male patient presented to the Jewish General Hospital with a 4-month history of neck discomfort, radicular pain in the proximal right arm, and mild weakness of the right biceps and triceps muscles. Imaging was suggestive of EOB, and computed tomography-guided biopsy confirmed the diagnosis. The patient underwent same-day preoperative angioembolization of the major feeding vessels and subsequent complete tumor resection. During the procedure, he experienced minimal blood loss and did not require blood transfusion.

EOB is a highly vascular primary bony lesion. To minimize intraoperative blood loss, preoperative angioembolization should be considered in the treatment of cervical spine EOB 3).


A 34-year-old gentleman from Lucknow who presented with a mass involving the left side of the neck and oral cavity along with ipsilateral lower cranial nerve paresis. Computed tomography and magnetic resonance imaging scans of the craniovertebral junction revealed a heterogeneously enhancing expansile lesion with areas of destruction involving the clivus, left sided jugular foramen and left side of first two cervical vertebras. Angiography showed distortion of the V3 segment of the left vertebral artery and shift of the ipsilateral internal carotid artery. The tumor was maximally excised through far lateral approach. Histopathologic examination revealed a diagnosis of AO. The patient was referred for radiotherapy for the residual tumor and was doing well at 5 months follow-up 4).

References

1) Jia Q, Liu C, Yang J, Yin H, Zhao J, Wei H, Liu T, Yang X, Yang C, Zhou Z, Xiao J. Factors Affecting Prognosis of Patients With Osteoblastoma of the Mobile Spine: A Long-Term Follow-up Study of 70 Patients in a Single Center. Neurosurgery. 2018 Nov 27. doi: 10.1093/neuros/nyy570. [Epub ahead of print] PubMed PMID: 30481353.2) Attiah M, Tucker AM, Niu T, Nagasawa DT, Kodrat E, Martin NA, Nelson S. Epithelioid Osteoblastoma of the Temporal Bone: A Case Report. World Neurosurg. 2018 Dec 3. pii: S1878-8750(18)32768-2. doi: 10.1016/j.wneu.2018.11.209. [Epub ahead of print] PubMed PMID: 30521959.3) Schur S, Camlioglu E, Jung S, Powell T, Gutman G, Golan J. Preoperative Embolization and Complete Tumoral Resection of a Cervical Aggressive Epithelioid Osteoblastoma. World Neurosurg. 2017 Oct;106:1051.e1-1051.e4. doi: 10.1016/j.wneu.2017.06.183. Epub 2017 Jul 12. PubMed PMID: 28710051.4) Singh DK, Das KK, Mehrotra A, Srivastava AK, Jaiswal AK, Gupta P, Behari S, Kumar R. Aggressive osteoblastoma involving the craniovertebral junction: A case report and review of literature. J Craniovertebr Junction Spine. 2013 Jul;4(2):69-72. doi: 10.4103/0974-8237.128533. PubMed PMID: 24744565; PubMed Central PMCID: PMC3980559.

Carotid endarterectomy for symptomatic low-grade carotid artery stenosis

A study of Kyoto and Kurashiki, aimed to assess the safety, efficacy, and durability of carotid endarterectomy (CEA) for symptomatic low-grade carotid artery stenosis (LGS).

Study participants comprised 61 consecutive patients who underwent CEA for symptomatic carotid artery stenosis. Patients were divided into an LGS group (<50%, n=17) and a non-LGS group (≥50%, n=44). Patient characteristics and short- (within 30 days of CEA) and long-term outcomes were compared between groups for selective usage of internal shunt and the known complications of CEA.

MRI-detected intraplaque hemorrhage was more significant in LGS than in non-LGS (P = .04). For short-term outcomes, no symptomatic infarcts, hyperperfusion syndrome, or acute myocardial infarction (AMI) was confirmed in either group. Internal shunts were used in 4 LGS (23.5%) and 6 non-LGS (13.6%). Asymptomatic diffusion-weighted imaging-positive lesions were confirmed in 2 LGS patients (11.8%) and 5 non-LGS patients (11.4%), neck hematoma in 1 LGS patient, and transient cranial nerve palsy in 1 LGS patient and 2 non-LGS patients, with no significant differences apparent between groups. For long-term outcomes, 5 non-LGS patients showed restenosis (P = .17). Hemorrhagic stroke was not observed in either group. No significant differences were seen for infarct in the ipsilateral carotid territory, any ischemic stroke, AMI, or mortality.

CEA represents a safe and feasible therapeutic option for a subset of patients with symptomatic LGS 1).1) Yoshida K, Fukumitsu R, Kurosaki Y, Nagata M, Tao Y, Suzuki M, Yamamoto Y, Funaki T, Kikuchi T, Ishii A, Miyamoto S. Carotid Endarterectomyfor Medical Therapy-resistant Symptomatic Low-grade Stenosis. World Neurosurg. 2018 Dec 3. pii: S1878-8750(18)32767-0. doi: 10.1016/j.wneu.2018.11.208. [Epub ahead of print] PubMed PMID: 30521960.

Suboccipital decompressive craniectomy due to space-occupying cerebellar infarction

All patients treated with suboccipital decompressive craniectomy (SDC) due to space-occupying cerebellar infarction between January 2009 and October 2015 in the Rigshospitalet, were included in the study. Data was retrospectively collected from patient records, CT/MRI scans and surgical protocols. Long-term functional outcome was determined by the modified Rankin Scale (mRS) and mRS ≥ 4 was defined as unfavorable outcome.

Twenty-two patients (16 male, 6 female) were included in the study. Median age was 53 years. Nine patients were treated with external ventricular drainage as an initial treatment attempt prior to SDC. Median time from symptom onset (stroke ictus) to initiation of the SDC surgery was 48 h (IQR 28-99 hours) and median GCS before SDC was 8 (IQR 5-10). At follow up, median mRS was 3 (IQR 2-6). Outcome was favorable (mRS 0-3) in 12 patients and unfavorable in 10 (3 with major disability, 7 dead). Brainstem infarction and bilateral cerebellar infarction were associated with unfavorable outcome.

In this small study, functional long-term outcome in patients with space-occupying cerebellar infarction treated by SDC was acceptable and comparable to previously published results (favorable outcome in 54% of patients). Brainstem infarction and bilateral cerebellar infarction were associated with unfavorable outcome 1).1) Lindeskog D, Lilja-Cyron A, Kelsen J, Juhler M. Long-term functional outcome after decompressive suboccipital craniectomy for space-occupying cerebellar infarction. Clin Neurol Neurosurg. 2018 Dec 1;176:47-52. doi: 10.1016/j.clineuro.2018.11.023. [Epub ahead of print] PubMed PMID: 30522035.

Unruptured intracranial aneurysm treatment decision

For a treatment decision of unruptured intracranial aneurysmphysicians and patients need to weigh the risk of treatment against the risk of hemorrhagic stroke caused by aneurysm rupture.

In a study of Detmer et al. Image segmentation data and patient information obtained from two patient cohorts including 203 patients with 249 aneurysms were used for patient-specific computational fluid dynamics simulations and subsequent evaluation of the statistical model in terms of accuracydiscrimination, and goodness of fit. The model’s performance was further compared to a similarity-based approach for rupture assessment by identifying aneurysms in the training cohort that were similar in terms of intracranial aneurysm hemodynamics and shape compared to a given aneurysm from the external cohorts.

When applied to the external data, the model achieved a good discrimination and goodness of fit (area under the receiver operating characteristic curve AUC = 0.82), which was only slightly reduced compared to the optimism-corrected AUC in the training population (AUC = 0.84). The accuracy metrics indicated a small decrease in accuracy compared to the training data (misclassification error of 0.24 vs. 0.21). The model’s prediction accuracy was improved when combined with the similarity approach (misclassification error of 0.14).

The model’s performance measures indicated a good generalizability for data acquired at different clinical institutions. Combining the model-based and similarity-based approach could further improve the assessment and interpretation of new cases, demonstrating its potential use for clinical unruptured intracranial aneurysm rupture risk assessment 1).

Scores

see also Unruptured intracranial aneurysm treatment score.

Unruptured intracranial aneurysm repair is the most commonly performed procedure for the prevention of hemorrhagic stroke. Despite efforts to regionalize care in high-volume centers, overall results have improved little 2).

The management of small unruptured incidentally discovered intracranial aneurysms (SUIAs) is still controversial.

Despite large trials supporting the management of small asymptomatic aneurysms, most neurosurgeons internationally chooses to treat them with surgery or endovascular means. Since clinicians use a number of factors beyond the maximum diameter when considering treatment options, future trials should consider these factors in their design 3).

Once a decision has been made to treat an intact aneurysm, the best treatment remains uncertain. Both surgical and endovascular management strategies are commonly performed for these lesions.

No one knows how best to manage these patients (an estimated 2—5% of the adult population), but with the increasing accessibility of non-invasive imaging, physicians are increasingly faced with the dilemma of what to do 4).

One stance maintains that the only acceptable rationale for a preventive treatment is randomised evidence that therapy does more good than harm. Thus, a randomised trial showing better outcomes for treated patients compared with conservatively managed patients would be necessary to justify invasive treatment of UIAs. However, this trial has not yet been successfully completed.

Posterior circulation in surgery, large aneurysms (>15 mm) in EVT, and stent- or balloon-assisted procedures in EVT were associated with the occurrence of complications. Poor clinical outcome (mRS of 3-6) was 0.8 % at hospital discharge.1) Detmer FJ, Fajardo-Jiménez D, Mut F, Juchler N, Hirsch S, Pereira VM, Bijlenga P, Cebral JR. External validation of cerebral aneurysm rupture probability model with data from two patient cohorts. Acta Neurochir (Wien). 2018 Dec;160(12):2425-2434. doi: 10.1007/s00701-018-3712-8. Epub 2018 Oct 30. PubMed PMID: 30374656.2) Zacharia BE, Bruce SS, Carpenter AM, Hickman ZL, Vaughan KA, Richards C, Gold WE, Lu J, Appelboom G, Solomon RA, Connolly ES. Variability in outcome after elective cerebral aneurysm repair in high-volume academic medical centers. Stroke. 2014 May;45(5):1447-52. doi: 10.1161/STROKEAHA.113.004412. Epub 2014 Mar 25. PubMed PMID: 24668204.3) Alshafai N, Falenchuk O, Cusimano MD. Practises and controversies in the management of asymptomatic aneurysms: Results of an international survey. Br J Neurosurg. 2015 Nov 5:1-7. [Epub ahead of print] PubMed PMID: 26540183.4) Raymond J, Darsaut TE, Molyneux AJ. A trial on unruptured intracranial aneurysms (the TEAM trial): results, lessons from a failure and the necessity for clinical care trials. Trials 2011; 12: 64.

Long-term outcome in intraspinal dermoid and epidermoid tumors

The purpose of the study of Wang et al. from the Peking Union Medical College Hospital, was to review the progression free survival (PFS), overall survival (OS), and long-term outcome in a consecutive series of 57 patients with intraspinal dermoid and epidermoid tumors.

A total of 57 patients who underwent surgery at the Peking Union Medical College Hospital between 2002 and 2010 were reviewed. Patients outcome were determined using the Japanese Orthopaedic Association scale (JOA) and the McCormick score.

The follow-up data were 100% complete and the median follow-up time was 9.2 years. Gross total resection was performed in 21 patients (36.84%) and subtotal resection in 36 patients (63.16%). The PFS and OS at 8 years were 78.95% and 100% respectively. A good outcome was observed in 56.14% of patients based on the JOA and McCormick score. The univariate analysis showed that a tumor size of more than 4 cm, subtotal resection and sphincter disturbances were the influencing factors of poor outcome.

The gold standard treatment for intraspinal tumors is gross total resection, but the operation needs to protect the remaining nerve function as much as possible and follow-up should be focused on patients with a high risk of poor outcome 1).Edit1) Wang X, Gao J, Wang T, Li Z, Li Y. Intraspinal dermoid and epidermoid cysts: Long-term outcome and risk factors. J Spinal Cord Med. 2018 Dec 5:1-6. doi: 10.1080/10790268.2018.1553008. [Epub ahead of print] PubMed PMID: 30517826.

Sedatives and opioids used during deep brain stimulation (DBS)

Sedatives and opioids used during deep brain stimulation (DBS) surgery interfere with optimal target localization and add to side effects and risks, and thus should be minimized.

To retrospectively test the actual need for sedatives and opioids when cranial nerve blocks and specific therapeutic communication are applied.

In a case series, 64 consecutive patients Zech et al. from University Hospital Regensburg, treated with a strong rapport, constant contact, non-verbal communication and hypnotic suggestions, such as dissociation to a “safe place,” reframing of disturbing noises and self-confirmation, and compared to 22 preceding patients under standard general anesthesia or conscious sedation.

With introduction of the protocol the need for sedation dropped from 100% in the control group to 5%, and from a mean dose of 444 mg to 40 mg in 3 patients. Remifentanil originally used in 100% of the patients in an average dose of 813 µg was reduced in the study group to 104 µg in 31% of patients. There were no haemodynamic reactions indicative of stress during incision, trepanationelectrode insertion and closure.

With adequate therapeutic communication, patients do not require sedation and no or only low-dose opioid treatment during DBS surgery, leaving patients fully awake and competent during surgery and testing 1)1) Zech N, Seemann M, Seyfried TF, Lange M, Schlaier J, Hansen E. Deep Brain Stimulation Surgery without Sedation. Stereotact Funct Neurosurg. 2018 Dec 5:1-9. doi: 10.1159/000494803. [Epub ahead of print] PubMed PMID: 30517938.

Association of hydrocephalus with neural tube defect

In a retrospective study of the association of hydrocephalus with neural tube defect (spina bifida or cephalocele) managed over a period of 7 years at the Department of Neurosurgery, University Hospital Yalgado Ouedraogo, thirty-eight cases were included. The mean age was 8.1 months, and the sex ratio was 0.81. There were 27 cases of spina bifida and 11 cases of cephalocele associated with hydrocephalus. A cerebral CT scan was performed in all patients. In 30 cases, the operative management of these pathologies was performed at the same operative time. Eight cases were operated in 2 separate operative stages with a mean time of 30 days between the 2 operations. The course was favorable in 22 patients operated by the simultaneous approach and in 3 patients operated by the separate approach (p = 0.07).

Surgical management of the association of hydrocephalus with neural tube defect in 1 or 2 operative stages gave similar clinical results. However, the treatment in 1 surgical stage would considerably reduce the charges 1).1) Zabsonre DS, Lankoande H, Zoungrana/Ouattara CFC, Thiombiano A, Ouedraogo S, Sanou A, Yameogo P, Kaboret-Douamba SJE, Kabre A. Association of Hydrocephalus with Neural Tube Defect: Our Experience with the Surgical Treatment in One or in Two Operative Stages (on Separate Days). Pediatr Neurosurg. 2018 Dec 5:1-5. doi: 10.1159/000494562. [Epub ahead of print] PubMed PMID: 30517948.

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