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Open access

Christina Jackson, Derek Kai Kong, Zachary C. Gersey, Eric W. Wang, Georgios Zenonos, Carl H. Snyderman, and Paul A. Gardner

Intraoperative distinction of pituitary adenoma from normal gland is critical in maximizing tumor resection without compromising pituitary function. Contact endoscopy provides a noninvasive technique that allows for real-time in vivo visualization of differences in tissue vascularity. Two illustrative cases of endoscopic endonasal approaches (EEAs) for resection of pituitary adenoma illustrate the use of contact endoscopy in identifying tumor from gland and differentiating a thin section of normal gland draped over the underlying tumor, thereby allowing for safe extracapsular tumor resection. Contact endoscopy may be used as an adjunct for intraoperative, in vivo differentiation of pituitary gland and adenoma.

The video can be found here: https://stream.cadmore.media/r10.3171/2021.10.FOCVID21199

Open access

Alexander J. Schupper, Jorge A. Roa, and Constantinos G. Hadjipanayis

Maximal safe resection is the primary goal of glioma surgery. By incorporating improved intraoperative visualization with the 3D exoscope combined with 5-ALA fluorescence, in addition to neuronavigation and diffusion tensor imaging (DTI) fiber tracking, the safety of resection of tumors in eloquent brain regions can be maximized. This video highlights some of the various intraoperative adjuncts used in brain tumor surgery for high-grade glioma.

In this case, the authors highlight the resection of a left posterior temporal lobe high-grade glioma in a 33-year-old patient, who initially presented with seizures, word-finding difficulty, and right-sided weakness. They demonstrate the multiple surgical adjuncts used both before and during surgical resection, and how multiple adjuncts can be effectively orchestrated to make surgery in eloquent brain areas safer for patients. Patient consent was obtained for publication.

The video can be found here: https://stream.cadmore.media/r10.3171/2021.10.FOCVID21174

Open access

Adam M. Olszewski, Bruce I. Tranmer, and Brandon D. Liebelt

Maximum safe resection remains a primary goal in the treatment of glioblastoma, with gross-total resection conveying additional survival benefit. Multiple intraoperative visualization techniques have been developed to improve the extent of resection. Herein, the authors describe the use of fluorescein and endoscopic assistance with a novel microinspection device in achieving a gross-total resection of a deep seated precuneal glioblastoma. An interhemispheric transfalcine approach was utilized and microsurgical resection was completed with fluorescein guidance. A 45° endoscope was then used to inspect the resection bed, and remaining areas of concern were then resected under endoscopic visualization.

The video can be found here: https://stream.cadmore.media/r10.3171/2021.10.FOCVID21195

Free access

Asham Khan, Mohamed A. R. Soliman, Nathan J. Lee, Muhammad Waqas, Joseph M. Lombardi, Venkat Boddapati, Lauren C. Levy, Jennifer Z. Mao, Paul J. Park, Justin Mathew, Ronald A. Lehman Jr., Jeffrey P. Mullin, and John Pollina

OBJECTIVE

Pedicle screw insertion for stabilization after lumbar fusion surgery is commonly performed by spine surgeons. With the advent of navigation technology, the accuracy of pedicle screw insertion has increased. Robotic guidance has revolutionized the placement of pedicle screws with 2 distinct radiographic registration methods, the scan-and-plan method and CT-to-fluoroscopy method. In this study, the authors aimed to compare the accuracy and safety of these methods.

METHODS

A retrospective chart review was conducted at 2 centers to obtain operative data for consecutive patients who underwent robot-assisted lumbar pedicle screw placement. The newest robotic platform (Mazor X Robotic System) was used in all cases. One center used the scan-and-plan registration method, and the other used CT-to-fluoroscopy for registration. Screw accuracy was determined by applying the Gertzbein-Robbins scale. Fluoroscopic exposure times were collected from radiology reports.

RESULTS

Overall, 268 patients underwent pedicle screw insertion, 126 patients with scan-and-plan registration and 142 with CT-to-fluoroscopy registration. In the scan-and-plan cohort, 450 screws were inserted across 266 spinal levels (mean 1.7 ± 1.1 screws/level), with 446 (99.1%) screws classified as Gertzbein-Robbins grade A (within the pedicle) and 4 (0.9%) as grade B (< 2-mm deviation). In the CT-to-fluoroscopy cohort, 574 screws were inserted across 280 lumbar spinal levels (mean 2.05 ± 1.7 screws/ level), with 563 (98.1%) grade A screws and 11 (1.9%) grade B (p = 0.17). The scan-and-plan cohort had nonsignificantly less fluoroscopic exposure per screw than the CT-to-fluoroscopy cohort (12 ± 13 seconds vs 11.1 ± 7 seconds, p = 0.3).

CONCLUSIONS

Both scan-and-plan registration and CT-to-fluoroscopy registration methods were safe, accurate, and had similar fluoroscopy time exposure overall.

Free access

Karim A. Shafi, Yuri A. Pompeu, Avani S. Vaishnav, Eric Mai, Ahilan Sivaganesan, Pratyush Shahi, and Sheeraz A. Qureshi

OBJECTIVE

The accuracy of percutaneous pedicle screw placement has increased with the advent of robotic and surgical navigation technologies. However, the effect of robotic intraoperative screw size and trajectory templating remains unclear. The purpose of this study was to compare pedicle screw sizes and accuracy of placement using robotic navigation (RN) versus skin-based intraoperative navigation (ION) alone in minimally invasive lumbar fusion procedures.

METHODS

A retrospective cohort study was conducted using a single-institution registry of spine procedures performed over a 4-year period. Patients who underwent 1- or 2-level primary or revision minimally invasive surgery (MIS)–transforaminal lumbar interbody fusion (TLIF) with pedicle screw placement, via either robotic assistance or surgical navigation alone, were included. Demographic, surgical, and radiographic data were collected. Pedicle screw type, quantity, length, diameter, and the presence of endplate breach or facet joint violation were assessed. Statistical analysis using the Student t-test and chi-square test was performed to evaluate the differences in pedicle screw sizes and the accuracy of placement between both groups.

RESULTS

Overall, 222 patients were included, of whom 92 underwent RN and 130 underwent ION MIS-TLIF. A total of 403 and 534 pedicle screws were placed with RN and ION, respectively. The mean screw diameters were 7.25 ± 0.81 mm and 6.72 ± 0.49 mm (p < 0.001) for the RN and ION groups, respectively. The mean screw length was 48.4 ± 4.48 mm in the RN group and 45.6 ± 3.46 mm in the ION group (p < 0.001). The rates of “ideal” pedicle screws in the RN and ION groups were comparable at 88.5% and 88.4% (p = 0.969), respectively. The overall screw placement was also similar. The RN cohort had 63.7% screws rated as good and 31.4% as acceptable, while 66.1% of ION-placed screws had good placement and 28.7% had acceptable placement (p = 0.661 and p = 0.595, respectively). There was a significant reduction in high-grade breaches in the RN group (0%, n = 0) compared with the ION group (1.2%, n = 17, p = 0.05).

CONCLUSIONS

The results of this study suggest that robotic assistance allows for placement of screws with greater screw diameter and length compared with surgical navigation alone, although with similarly high accuracy. These findings have implied that robotic platforms may allow for safe placement of the “optimal screw,” maximizing construct stability and, thus, the ability to obtain a successful fusion.

Open access

Christopher S. Graffeo, Visish M. Srinivasan, Tyler S. Cole, and Michael T. Lawton

Mycotic brain aneurysms are rare and unusual cerebrovascular lesions arising from septic emboli that degrade the elastic lamina and vessel wall of intracranial arteries, which results in pathologic dilatation. Mycotic aneurysms are nonsaccular lesions that are not often suitable for clipping and instead require bypass, trapping, and flow reversal. This case demonstrates the use of indocyanine green “flash fluorescence” to identify the cortical distribution supplied by an aneurysm’s outflow, facilitating safe treatment with a double-barrel extracranial-intracranial bypass and partial trapping and conversion of a deep bypass to a superficial one.

The video can be found here: https://stream.cadmore.media/r10.3171/2021.10.FOCVID21163

Free access

Daniel Lubelski and Nicholas Theodore

Free access

George Chandy Vilanilam and Easwer Hariharan Venkat

Free access

Anant Naik, Alexander D. Smith, Annabelle Shaffer, David T. Krist, Christina M. Moawad, Bailey R. MacInnis, Kevin Teal, Wael Hassaneen, and Paul M. Arnold

OBJECTIVE

Several approaches have been studied for internal fixation of the spine using pedicle screws (PSs), including CT navigation, 2D and 3D fluoroscopy, freehand, and robotic assistance. Robot-assisted PS placement has been controversial because training requirements, cost, and previously unclear benefits. This meta-analysis compares screw placement accuracy, operative time, intraoperative blood loss, and overall complications of PS insertion using traditional freehand, navigated, and robot-assisted methods.

METHODS

A systematic review was performed of peer-reviewed articles indexed in several databases between January 2000 and August 2021 comparing ≥ 2 PS insertion methods with ≥ 10 screws per treatment arm. Data were extracted for patient outcomes, including PS placement, misplacement, and accuracy; operative time, overall complications, intraoperative blood loss, postoperative hospital length of stay, postoperative Oswestry Disability Index (ODI) score, and postoperative visual analog scale (VAS) score for back pain. Risk of bias was assessed using the Newcastle-Ottawa score and Cochrane tool. A network meta-analysis (NMA) was performed to estimate PS placement accuracy as the primary outcome.

RESULTS

Overall, 78 studies consisting of 6262 patients and > 31,909 PSs were included. NMA results showed that robot-assisted and 3D-fluoroscopy PS insertion had the greatest accuracy compared with freehand (p < 0.01 and p < 0.001, respectively), CT navigation (p = 0.02 and p = 0.04, respectively), and 2D fluoroscopy (p < 0.01 and p < 0.01, respectively). The surface under the cumulative ranking (SUCRA) curve method further demonstrated that robot-assisted PS insertion accuracy was superior (S = 0.937). Optimal screw placement was greatest in robot-assisted (S = 0.995) placement, and misplacement was greatest with freehand (S = 0.069) approaches. Robot-assisted placement was favorable for minimizing complications (S = 0.876), while freehand placement had greater odds of complication than robot-assisted (OR 2.49, p < 0.01) and CT-navigation (OR 2.15, p = 0.03) placement.

CONCLUSIONS

The results of this NMA suggest that robot-assisted PS insertion has advantages, including improved accuracy, optimal placement, and minimized surgical complications, compared with other PS insertion methods. Limitations included overgeneralization of categories and time-dependent effects.

Open access

Quan Zhou and Gordon Li

A contrast-enhancing lesion in the left temporal lobe of a 72-year-old woman was biopsied and diagnosed as glioblastoma. Near-infrared (NIR)–labeled epidermal growth factor receptor (EGFR) antibody, panitumumab-IRDye800, was infused 52 hours before craniotomy without pretreatment. Tumor fluorescence was detected through intact dura, and the visual contrast between disease and peritumoral healthy brain was enhanced after tumor exposure. Residual cancerous tissue was identified with strong fluorescence in resection cavity after en bloc tumor removal. Minimal fluorescence remained in the final wound bed, likely from nonenhancing tumor. Fluorescence was heterogeneously distributed at the infiltrative margin in resected tumor pieces imaged ex vivo. Postoperative MRI confirmed gross-total resection.

The video can be found here: https://stream.cadmore.media/r10.3171/2021.10.FOCVID21201