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Open access

Fraser Henderson Jr., Evgenii Belykh, Alexander D. Ramos, and Theodore H. Schwartz

Fluorescence-guided surgery (FGS) for high-grade gliomas using 5-aminolevulinic acid has become a new standard of care for neurosurgeons in several countries. In this video the authors present the case of a man with glioblastoma who underwent FGS in which similar images of the operative field were acquired alternating between the microscope and a new commercially available headlight, facilitating the comparison of visualization quality between the two devices. The authors also review some of the principles of fluorescence-guidance surgery that may explain the improved brightness and contrast that they observed when using the headlamp versus the microscope.

The video can be found here: https://stream.cadmore.media/r10.3171/2021.10.FOCVID21181

Free access

Kathrin Machetanz, Florian Grimm, Sophie Wang, Martin U. Schuhmann, Marcos Tatagiba, Alireza Gharabaghi, and Georgios Naros

OBJECTIVE

Conventional frame-based stereotaxy through a transfrontal approach (TFA) is the gold standard in brainstem biopsies. Because of the high surgical morbidity and limited impact on therapy, brainstem biopsies are controversial. The introduction of robot-assisted stereotaxy potentially improves the risk-benefit ratio by simplifying a transcerebellar approach (TCA). The aim of this single-center cohort study was to evaluate the risk-benefit ratio of transcerebellar brainstem biopsies performed by 2 different robotic systems. In addition to standard quality indicators, a special focus was set on trajectory selection for reducing surgical morbidity.

METHODS

This study included 25 pediatric (n = 7) and adult (n = 18) patients who underwent 26 robot-assisted biopsies via a TCA. The diagnostic yield, complication rate, trajectory characteristics (i.e., length, anatomical entry, and target-point location), and skin-to-skin (STS) time were evaluated. Transcerebellar and hypothetical transfrontal trajectories were reconstructed and transferred into a common MR space for further comparison with anatomical atlases.

RESULTS

Robot-assisted, transcerebellar biopsies demonstrated a high diagnostic yield (96.2%) while exerting no surgical mortality and no permanent morbidity in both pediatric and adult patients. Only 3.8% of cases involved a transient neurological deterioration. Transcerebellar trajectories had a length of 48.4 ± 7.3 mm using a wide stereotactic corridor via crus I or II of the cerebellum and the middle cerebellar peduncle. The mean STS time was 49.5 ± 23.7 minutes and differed significantly between the robotic systems (p = 0.017). The TFA was characterized by longer trajectories (107.4 ± 11.8 mm, p < 0.001) and affected multiple eloquent structures. Transfrontal target points were located significantly more medial (−3.4 ± 7.2 mm, p = 0.042) and anterior (−3.9 ± 8.4 mm, p = 0.048) in comparison with the transcerebellar trajectories.

CONCLUSIONS

Robot-assisted, transcerebellar stereotaxy can improve the risk-benefit ratio of brainstem biopsies by avoiding the restrictions of a TFA and conventional frame-based stereotaxy. Profound registration and anatomical-functional trajectory selection were essential to reduce mortality and morbidity.

Free access

Rawad Abbas, Fadi Al Saiegh, Kareem El Naamani, Ching-Jen Chen, Lohit Velagapudi, Georgios S. Sioutas, Joshua H. Weinberg, Stavropoula Tjoumakaris, M. Reid Gooch, Nabeel A. Herial, Robert H. Rosenwasser, and Pascal Jabbour

OBJECTIVE

Over the past 2 decades, robots have been increasingly used in surgeries to help overcome human limitations and perform precise and accurate tasks. Endovascular robots were pioneered in interventional cardiology, however, the CorPath GRX was recently approved by the FDA for peripheral vascular and extracranial interventions. The authors aimed to evaluate the operational learning curve for robot-assisted carotid artery stenting over a period of 19 months at a single institution.

METHODS

A retrospective analysis of a prospectively maintained database was conducted, and 14 consecutive patients who underwent robot-assisted carotid artery stenting from December 2019 to June 2021 were identified. The metrics for proficiency were the total fluoroscopy and procedure times, contrast volume used, and radiation dose. To evaluate operator progress, the patients were divided into 3 groups of 5, 4, and 5 patients based on the study period.

RESULTS

A total of 14 patients were included. All patients received balloon angioplasty and stent placement. The median degree of stenosis was 95%. Ten patients (71%) were treated via the transradial approach and 4 patients (29%) via the transfemoral approach, with no procedural complications. The median contrast volume used was 80 mL, and the median radiation dose was 38,978.5 mGy/cm2. The overall median fluoroscopy and procedure times were 24.6 minutes and 70.5 minutes, respectively. Subgroup analysis showed a significant decrease in these times, from 32 minutes and 86 minutes, respectively, in group 1 to 21.9 minutes and 62 minutes, respectively, in group 3 (p = 0.002 and p = 0.008, respectively).

CONCLUSIONS

Robot-assisted carotid artery stenting was found to be safe and effective, and the learning curve for robotic procedures was overcome within a short period of time at a high-volume cerebrovascular center.

Free access

Suhas Udayakumaran, Arjun Krishnadas, and Pramod Subash

OBJECTIVE

In this study, the authors aimed to 1) retrospectively analyze the early functional outcomes in a cohort of very young children with craniofacial dysostoses who underwent robot-assisted frontofacial advancement (RAFFA) or robot-assisted midface distraction (RAMD), and 2) analyze the utility of robotic assistance in improving the accuracy and safety of performing transfacial pin insertion for RAFFA or RAMD.

METHODS

A retrospective analysis of a cohort of 18 children (age range 1–42 months at presentation), who underwent RAFFA or RAMD from February 2015 to February 2021 in the craniofacial unit at Amrita Institute of Medical Sciences and Research Centre in Kochi, India, was performed. Inclusion criteria were patients who had undergone RAFFA in a single stage or RAMD where the cranial vault had been addressed earlier, had been addressed on follow-up, or had not been addressed and had follow-up of at least 6 months.

RESULTS

Overall, 18 children with syndromic craniosynostosis underwent LeFort level III midface distraction, with or without RAFFA, from February 2015 to February 2021 at a single center in India. The patients’ ages ranged from 6 to 47 months at the time of the procedure. All patients had significant obstructive sleep apnea (OSA), significant ocular issues, and disturbed sleep as determined by the authors’ preoperative protocol. Clinically significant intracranial pressure issues were present in 17 patients. None of the patients had injury due to the transfacial pin trajectory such as globe injury, damage to the tooth buds, or the loss of purchase during the active distraction phase. The mean distraction achieved was 23 mm (range 18–30 mm) (n = 16/18). Of the 18 patients, 10 (56%) had an excellent outcome and 6 (33%) had a satisfactory outcome. In all cases, the degree of OSA had significantly reduced after surgery. Eye closure improved in all patients, and complete closure was seen in 11 patients. On follow-up, the functional gain remained in 14 of 16 patients at the final follow-up visit. The distraction results were stable during the follow-up period (mean 36 months [range 6–72 months]).

CONCLUSIONS

The early RAFFA and RAMD protocols investigated in this study gave a significant functional advantage in very young patients with craniofacial dysostoses. The results have demonstrated the accuracy and safety of robotic assistance in performing transfacial pin insertion for RAFFA or RAMD.

Free access

Ming-Chin Lin, Heng-Wei Liu, Yu-Kai Su, Wei-Lun Lo, and Chien-Min Lin

OBJECTIVE

The use of robotics in spinal surgery has gained popularity because of its promising accuracy and safety. ROSA is a commonly used surgical robot system for spinal surgery. The aim of this study was to compare outcomes between robot-guided and freehand fluoroscopy-guided instrumentation in minimally invasive surgery (MIS)–transforaminal lumbar interbody fusion (TLIF).

METHODS

This retrospective consecutive series reviewed 224 patients who underwent MIS-TLIF from March 2019 to April 2020 at a single institution. All patients were diagnosed with degenerative pathologies. Of those, 75 patients underwent robot-guided MIS-TLIF, and 149 patients underwent freehand fluoroscopy-guided MIS-TLIF. The incidences of pedicle breach, intraoperative outcomes, postoperative outcomes, and short-term pain control were compared.

RESULTS

The patients who underwent robot-guided surgery had a lower incidence of pedicle breach (0.27% vs 1.75%, p = 0.04) and less operative blood loss (313.7 ± 214.1 mL vs 431.6 ± 529.8 mL, p = 0.019). Nonsignificant differences were observed in operative duration (280.7 ± 98.1 minutes vs 251.4 ± 112.0 minutes, p = 0.056), hospital stay (6.6 ± 3.4 days vs 7.3 ± 4.4 days, p = 0.19), complications (intraoperative, 1.3% vs 1.3%, p = 0.45; postoperative surgery-related, 4.0% vs 4.0%, p = 0.99), and short-term pain control (postoperative day 1, 2.1 ± 1.2 vs 1.8 ± 1.2, p = 0.144; postoperative day 30, 1.2 ± 0.5 vs 1.3 ± 0.7, p = 0.610). A shorter operative duration for 4-level spinal surgery was found in the robot-guided surgery group (388.7 ± 107.3 minutes vs 544.0 ± 128.5 minutes, p = 0.047).

CONCLUSIONS

This retrospective review revealed that patients who underwent robot-guided MIS-TLIF experienced less operative blood loss. They also benefited from a shorter operative duration with higher-level (> 3 levels) spinal surgery. The postoperative outcomes were similar for both robot-guided and freehand fluoroscopy-guided procedures.

Free access

Dhiraj J. Pangal, David J. Cote, Jacob Ruzevick, Benjamin Yarovinsky, Guillaume Kugener, Bozena Wrobel, Elisabeth H. Ference, Mark Swanson, Andrew J. Hung, Daniel A. Donoho, Steven Giannotta, and Gabriel Zada

OBJECTIVE

The utility of robotic instrumentation is expanding in neurosurgery. Despite this, successful examples of robotic implementation for endoscopic endonasal or skull base neurosurgery remain limited. Therefore, the authors performed a systematic review of the literature to identify all articles that used robotic systems to access the sella or anterior, middle, or posterior cranial fossae.

METHODS

A systematic review of MEDLINE and PubMed in accordance with PRISMA guidelines performed for articles published between January 1, 1990, and August 1, 2021, was conducted to identify all robotic systems (autonomous, semiautonomous, or surgeon-controlled) used for skull base neurosurgical procedures. Cadaveric and human clinical studies were included. Studies with exclusively otorhinolaryngological applications or using robotic microscopes were excluded.

RESULTS

A total of 561 studies were identified from the initial search, of which 22 were included following full-text review. Transoral robotic surgery (TORS) using the da Vinci Surgical System was the most widely reported system (4 studies) utilized for skull base and pituitary fossa procedures; additionally, it has been reported for resection of sellar masses in 4 patients. Seven cadaveric studies used the da Vinci Surgical System to access the skull base using alternative, non–TORS approaches (e.g., transnasal, transmaxillary, and supraorbital). Five cadaveric studies investigated alternative systems to access the skull base. Six studies investigated the use of robotic endoscope holders. Advantages to robotic applications in skull base neurosurgery included improved lighting and 3D visualization, replication of more traditional gesture-based movements, and the ability for dexterous movements ordinarily constrained by small operative corridors. Limitations included the size and angulation capacity of the robot, lack of drilling components preventing fully robotic procedures, and cost. Robotic endoscope holders may have been particularly advantageous when the use of a surgical assistant or second surgeon was limited.

CONCLUSIONS

Robotic skull base neurosurgery has been growing in popularity and feasibility, but significant limitations remain. While robotic systems seem to have allowed for greater maneuverability and 3D visualization, their size and lack of neurosurgery-specific tools have continued to prevent widespread adoption into current practice. The next generation of robotic technologies should prioritize overcoming these limitations.

Free access

Alexander D. Smith, Alexander J. Teague, Anant Naik, Mika Janbahan, Emily J. Smith, David T. Krist, Sindhu Parupalli, Kevin Teal, and Wael Hassaneen

OBJECTIVE

Emergency neurosurgical care in lower-middle-income countries faces pronounced shortages in neurosurgical personnel and infrastructure. In instances of traumatic brain injury (TBI), hydrocephalus, and subarachnoid hemorrhage, the timely placement of external ventricular drains (EVDs) strongly dictates prognosis and can provide necessary stabilization before transfer to a higher-level center of care that has access to neurosurgery. Accordingly, the authors have developed an inexpensive and portable robotic navigation tool to allow surgeons who do not have explicit neurosurgical training to place EVDs. In this article, the authors aimed to highlight income disparities in neurosurgical care, evaluate access to CT imaging around the world, and introduce a novel, inexpensive robotic navigation tool for EVD placement.

METHODS

By combining the worldwide distribution of neurosurgeons, CT scanners, and gross domestic product with the incidence of TBI, meningitis, and hydrocephalus, the authors identified regions and countries where development of an inexpensive, passive robotic navigation system would be most beneficial and feasible. A prototype of the robotic navigation system was constructed using encoders, 3D-printed components, machined parts, and a printed circuit board.

RESULTS

Global analysis showed Montenegro, Antigua and Barbuda, and Seychelles to be primary candidates for implementation and feasibility testing of the novel robotic navigation system. To validate the feasibility of the system for further development, its performance was analyzed through an accuracy study resulting in accuracy and repeatability within 1.53 ± 2.50 mm (mean ± 2 × SD, 95% CI).

CONCLUSIONS

By considering regions of the world that have a shortage of neurosurgeons and a high incidence of EVD placement, the authors were able to provide an analysis of where to prioritize the development of a robotic navigation system. Subsequently, a proof-of-principle prototype has been provided, with sufficient accuracy to target the ventricles for EVD placement.

Open access

Ritesh Karsalia, Nina H. Cheng, Clare W. Teng, Steve S. Cho, Stefan Harmsen, and John Y. K. Lee

A prospective trial evaluating the utility of second window indocyanine green (SWIG) in predicting postoperative MRI gadolinium enhancement was performed on high-grade gliomas (HGGs) and brain metastases. Compared to white light alone, SWIG demonstrated a higher sensitivity, negative predictive value, and accuracy in predicting residual neoplasm on MRI. The specificity of SWIG for predicting MRI enhancement was higher in HGGs than brain metastases. Clinically, near-infrared (NIR) imaging was better able to predict tumor recurrence than postoperative MRI. These results illustrate how SWIG is able to take advantage of gadolinium-like distribution properties to extravasate into the tumor microenvironment, enabling guidance in surgical resection.

The video can be found here: https://stream.cadmore.media/r10.3171/2021.10.FOCVID21204

Free access

Marton Berczeli, Ponraj Chinnadurai, Peter T. Legeza, Gavin W. Britz, and Alan B. Lumsden

OBJECTIVE

The purpose of this proof-of-concept study was to demonstrate the setup and feasibility of transcarotid access for remote robotic neurointerventions in a cadaveric model.

METHODS

The interventional procedures were performed in a fresh-frozen cadaveric model using an endovascular robotic system and a robotic angiography imaging system. A prototype remote, robotic-drive system with an ethernet-based network connectivity and audio-video communication system was used to drive the robotic system remotely. After surgical exposure of the common carotid artery in a cadaveric model, an 8-Fr arterial was inserted and anchored. A telescopic guiding sheath and catheter/microcatheter combination was modified to account for the “workable” length with the CorPath GRX robotic system using transcarotid access.

RESULTS

To simulate a carotid stenting procedure, a 0.014-inch wire was advanced robotically to the extracranial internal carotid artery. After confirming the wire position and anatomy by angiography, a self-expandable rapid exchange nitinol stent was loaded into the robotic cassette, advanced, and then deployed robotically across the carotid bifurcation. To simulate an endovascular stroke recanalization procedure, a 0.014-inch wire was advanced into the proximal middle cerebral artery with robotic assistance. A modified 2.95-Fr delivery microcatheter (Velocity, Penumbra Inc.) was loaded into the robotic cassette and positioned. After robotic retraction of the wire, it was switched manually to a mechanical thrombectomy device (Solitaire X, Medtronic). The stentriever was then advanced robotically into the end of the microcatheter. After robotic unfolding and short microcatheter retraction, the microcatheter was manually removed and the stent retriever was extracted using robotic assistance. During intravascular navigation, the device position was guided by 2D angiography and confirmed by 3D cone-beam CT angiography.

CONCLUSIONS

In this proof-of-concept cadaver study, the authors demonstrated the setup and technical feasibility of transcarotid access for remote robot-assisted neurointerventions such as carotid artery stenting and mechanical thrombectomy. Using transcarotid access, catheter length modifications were necessary to achieve “working length” compatibility with the current-generation CorPath GRX robotic system. While further improvements in dedicated robotic solutions for neurointerventions and next-generation thrombectomy devices are necessary, the transcarotid approach provides a direct, relatively rapid access route to the brain for delivering remote stroke treatment.

Open access

Alma Rechav Ben-Natan, Nitin Agarwal, Saman Shabani, Jason Chung, Vivian Le, Dean Chou, and Praveen V. Mummaneni

The development of the 3D exoscope has advanced intraoperative visualization by providing access to visual corridors that were previously difficult to obtain or maintain with traditional operating microscopes. Favorable ergonomics, maneuverability, and increased potential for instruction provide utility in a large range of procedures. Here, the authors demonstrate the exoscope system in a patient with progressive thoracolumbar junctional kyphosis with bony retropulsion of a T12–L1 fracture requiring a Schwab grade 5 osteotomy and fusion. The utilization of the exoscope provides visual access to the ventrolateral dura for the entire surgical team (surgeons, learners, and scrub nurse).

The video can be found here: https://stream.cadmore.media/r10.3171/2021.10.FOCVID21190