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Garnette R. Sutherland

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Taro Kaibara, R. John Hurlbert and Garnette R. Sutherland

✓ Transoral decompression of the cervicomedullary junction may be compromised by a narrow corridor in which surgery is performed, and thus the adequacy of surgical decompression/resection may be difficult to determine. This is problematic as the presence of spinal instrumentation may obscure the accuracy of postoperative radiological assessment, or the patient may require reoperation. The authors describe three patients in whom high-field intraoperative magnetic resonance (MR) images were acquired at various stages during the transoral resection of C-2 disease that had caused craniocervical junction compression.

All three patients harbored different lesions involving the cervicomedullary junction: one each of plasmacytoma and metastatic breast carcinoma involving the odontoid process and C-2 vertebral body, and basilar invagination with a Chiari I malformation. All patients presented with progressive myelopathy. Surgical planning MR imaging studies performed after the induction of anesthesia demonstrated the lesion and its relationship to the planned surgical corridor. Transoral exposure was achieved through placement of a Crockard retractor system. In one case the soft palate was divided. Interdissection MR imaging revealed that adequate decompression had been achieved in all cases. The two patients with carcinoma required placement of posterior instrumentation for stabilization. Planned suboccipital decompression and placement of instrumentation were averted in the third case as the intraoperative MR images demonstrated that excellent decompression had been achieved.

Intraoperatively acquired MR images were instrumental in determining the adequacy of the decompressive surgery. In one of the three cases, examination of the images led the authors to change the planned surgical procedure. Importantly, the acquisition of intraoperative MR images did not adversely affect operating time or neurosurgical techniques, including instrumentation requirements.

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Taro Kaibara, R. John Hurlbert and Garnette R. Sutherland

Object

Because transoral decompression of the cervicomedullary junction is compromised by a narrow surgical corridor, the adequacy of decompression/resection may be difficult to determine. This is problematic as spinal hardware may obscure postoperative radiological assessment, or the patient may require reoperation. The authors report three patients in whom high-field intraoperative magnetic resonance (MR) images were acquired at various stages during the transoral resection of C-2 lesions causing craniocervical junction compression.

Methods

In all three patients the lesions involved the cervicomedullary junction: one case each of plasmacytoma and metastatic breast carcinoma involving the odontoid process and C-2 vertebral body, and one case of basilar invagination with a Chiari type I malformation. All three patients presented with progressive myelopathy. Surgery-planning MR imaging studies, performed after the induction of anesthesia, demonstrated the lesion and its relationship to the planned surgical corridor. Transoral exposure was achieved through placement of a Crockard retractor system. In one case the soft palate was divided. Interdissection MR imaging revealed that adequate decompression had been achieved in all cases. In the two patients with carcinoma, posterior instrumentation was placed to achieve spinal stabilization. Planned suboccipital decompression and fixation was averted in the third case because MR imaging demonstrated that excellent decompression had been achieved.

Conclusions

Intraoperatively acquired MR images were instrumental in determining the adequacy of surgical decompression. In one patient the MR images changed the planned surgical procedure. Importantly, the acquisition of intraoperative MR images did not adversely affect operative time or neurosurgical techniques, including the instrumentation procedure.

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Deon F. Louw, Wilson T. Asfora and Garnette R. Sutherland

In this communication the authors outline the development of aneurysm clips from those originally used by Walter Dandy to those currently in use. The history is rich in contributions from neurosurgical pioneers and innovators. As a result, the modern neurosurgeon has a wide selection of biocompatible aneurysm clips with known closing pressure, of variable sizes and shapes, and a selection of clip applicators that do not obstruct the surgical field.

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Deon F. Louw, Taro Kaibara and Garnette R. Sutherland

✓ This communication outlines the development of aneurysm clips, from those originally used by Walter Dandy to those in use today. The history is rich, with many contributions from neurosurgical pioneers and innovators. As a result, the modern neurosurgeon has a wide selection of biocompatible aneurysm clips from which to choose, clips that have known closing pressures and various sizes and shapes, as well as a selection of clip applicators that do not obstruct the surgical field.

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Garnette R. Sutherland, Taro Kaibara, Deon Louw and John Saunders

The authors' goal was to place a mobile, 1.5 tesla magnetic resonance (MR) imaging system into a neurosurgical operating room without adversely affecting established neurosurgical management. The system would help to plan accurate surgical corridors, confirm the accomplishment of operative objectives, and detect acute complications such as hemorrhage or ischemia.

The authors used an actively shielded 1.5 tesla magnet, together with 15 m tesla/m gradients, MR console computers, gradient amplifiers, a titanium, hydraulic-controlled operating table, and a radio frequency coil that can be disassembled. The magnet is moved to and from the surgical field by using overhead crane technology. To date, the system has provided unfettered access to 46 neurosurgical patients.

In all patients, high-definition T1- and/or T2-weighted images were rapidly and reproducibly acquired at various stages of the surgical procedures. Eleven patients underwent craniotomy that was optimized after pre-incisional imaging. In four patients who harbored subtotally resected tumor, intraoperative MR imaging allowed removal of remaining tumor. Interestingly, the intraoperative administration of gadolinium in the management of patients with malignant glioma demonstrated a dynamic expansion of enhancement beyond the preoperative contrast contour. These zones of new enhancement proved, on examination of biopsy sample, to be tumor.

The authors have demonstrated that high-quality MR images can be obtained within reasonable time constraints in the operating room. Procedures can be conducted without compromising or altering traditional neurosurgical, nursing, or anesthetic techniques. It is feasible that within the next decade intraoperative MR imaging may become the standard of care in neurosurgery.

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Raman C. Mahabir, Artur Szymczak and Garnette R. Sutherland

✓ In this report the authors discuss a patient who experienced symptoms of an acute right frontal, intraparenchymal pneumatocele while on an airplane descending to an international airport. This rare complication of an ethmoid sinus osteoma that eroded upward through the dura mater is described along with a literature review. A persistent headache and inappropriate behavior consistent with a frontal lobe syndrome brought the patient to clinical and imaging evaluation, which revealed a large right frontal lobe pneumatocele and an associated ethmoid sinus osteoma extending upward into the frontal lobe. Through a right frontal craniotomy, the air cavity was evacuated, the osteoma partially excised, and the dural defect closed using a vascularized pericranial flap. Postoperatively, the patient made an unremarkable recovery. For patients with air sinus osteomas extending into the cranial cavity, air travel or other barotrauma may result in a life-threatening tension pneumatocele.

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Taro Kaibara, Garnette R. Sutherland, Fred Colbourne and Randy L. Tyson

Object. Hypothermia is used in neurosurgery and other surgical disciplines to reduce tissue injury, but the mechanism of such protection remains elusive. The authors have endeavored to delineate the mechanism of neural protection afforded by hypothermia through a study of glucose metabolism.

Methods. Nuclear magnetic resonance spectroscopy was used to follow the carbon-13 label from [1-13C]glucose as it was metabolized through the glycolytic and tricarboxylic acid pathways. Male Sprague—Dawley rats were maintained at either 37.5°C or 31°C and infused with labeled glucose for 10, 30, 60, 100, or 200 minutes (five rats were used for each time point and for each temperature). At the end of the infusion period, the rats' brains were subjected to rapid freeze-funnel fixation. Water-soluble metabolites were extracted from samples of the neocortex and hippocampus by using perchloric acid extraction. The fractional enrichment of these metabolites was used to calculate the reaction rate constant of formation and steady-state enrichment for a number of metabolites.

Hypothermia resulted in a 30 to 40% depression of metabolism (p < 0.0001) in both the neocortex and hippocampus. Steady-state fractional enrichment of metabolites was also decreased by 20 to 25% with hypothermia (p < 0.0001), implying a loss of label during metabolism.

Conclusions. The results of this study suggest that an increased fraction of glucose metabolism was shunted through the pentose phosphate pathway in the presence of hypothermia.

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Garnette R. Sutherland, Sanju Lama, Liu Shi Gan, Stefan Wolfsberger and Kourosh Zareinia

Object

It has been over a decade since the introduction of the da Vinci Surgical System into surgery. Since then, technology has been advancing at an exponential rate, and newer surgical robots are becoming increasingly sophisticated, which could greatly impact the performance of surgery. NeuroArm is one such robotic system.

Methods

Clinical integration of neuroArm, an MR-compatible image-guided robot, into surgical procedure has been developed over a prospective series of 35 cases with varying pathology.

Results

Only 1 adverse event was encountered in the first 35 neuroArm cases, with no patient injury. The adverse event was uncontrolled motion of the left neuroArm manipulator, which was corrected through a rigorous safety review procedure. Surgeons used a graded approach to introducing neuroArm into surgery, with routine dissection of the tumor-brain interface occurring over the last 15 cases. The use of neuroArm for routine dissection shows that robotic technology can be successfully integrated into microsurgery. Karnofsky performance status scores were significantly improved postoperatively and at 12-week follow-up.

Conclusions

Surgical robots have the potential to improve surgical precision and accuracy through motion scaling and tremor filters, although human surgeons currently possess superior speed and dexterity. Additionally, neuroArm's workstation has positive implications for technology management and surgical education. NeuroArm is a step toward a future in which a variety of machines are merged with medicine.