Fangyou Gao, Qu Wang, Chuangxi Liu, Bing Xiong and Tao Luo
This study was undertaken to evaluate the feasibility and efficacy of individualized 3D printed model–assisted posterior internal fixation in treating craniovertebral junction (CVJ) abnormalities.
Forty-four patients (19 males and 25 females; mean age 36.5 ± 9.2 years, range 11–62 years; symptom duration 1 month–15 years) with a CVJ abnormality who were admitted to the authors’ institution between April 2010 and April 2015 were retrospectively studied. The individualized 3D printed model of the CVJ was produced based on the individual CT data by use of 3D printing technology. The posterior internal fixation was simulated on the model to obtain data for individual patients, which were then used for intraoperative assistance. One-stage posterior decompression combined with internal fixation was performed. The results were evaluated using the Japanese Orthopaedic Association (JOA) scale, atlanto-dens interval (ADI), and cervicomedullary angle (CMA). The patients underwent follow-up and outcomes were evaluated using CT, MRI, and the JOA scale score. The comparison between preoperative and postoperative JOA scale scores was done using a paired t-test.
Thirty-eight individualized 3D printed models were successfully built. The 38 patients underwent successful posterior internal fixation performed with the assistance of 3D printed models. In the 6 patients without an individualized printed model (i.e., the patients who underwent surgery before 3D printed modeling was available at the authors’ institution), the pedicle screw was inserted incorrectly into the transverse foramen in 2 patients and inserted incorrectly into the vertebral canal in 1 patient. All patients were observed for a mean of 26 months (range 3–52 months). The postoperative JOA scale scores for all patients significantly improved from the preoperative scores. Among the 41 patients treated with atlantoaxial distraction reduction, postoperative MRI and CT showed complete reduction in 31 patients and incomplete reduction in 10 patients (reduction rate > 50%). The postoperative ADI significantly decreased, and the CMA significantly increased.
Individualized 3D printed model–assisted posterior internal fixation seems feasible and effective in optimizing the treatment of CVJ abnormalities. In addition, it offers many advantages, including preoperative simulation, intraoperatve guidance, and intraoperative error minimization.
Ye Li, Xiaolei Chen, Ning Wang, Wenyao Zhang, Dawei Li, Lei Zhang, Xin Qu, Weitao Cheng, Yueqiao Xu, Wenjin Chen and Qiumei Yang
The goal of this study was to explore the feasibility and accuracy of using a wearable mixed-reality holographic computer to guide external ventricular drain (EVD) insertion and thus improve on the accuracy of the classic freehand insertion method for EVD insertion. The authors also sought to provide a clinically applicable workflow demonstration.
Pre- and postoperative CT scanning were performed routinely by the authors for every patient who needed EVD insertion. Hologram-guided EVD placement was prospectively applied in 15 patients between August and November 2017. During surgical planning, model reconstruction and trajectory calculation for each patient were completed using preoperative CT. By wearing a Microsoft HoloLens, the neurosurgeon was able to visualize the preoperative CT-generated holograms of the surgical plan and perform EVD placement by keeping the catheter aligned with the holographic trajectory. Fifteen patients who had undergone classic freehand EVD insertion were retrospectively included as controls. The feasibility and accuracy of the hologram-guided technique were evaluated by comparing the time required, number of passes, and target deviation for hologram-guided EVD placement with those for classic freehand EVD insertion.
Surgical planning and hologram visualization were performed in all 15 cases in which EVD insertion involved holographic guidance. No adverse events related to the hologram-guided procedures were observed. The mean ± SD additional time before the surgical part of the procedure began was 40.20 ± 10.74 minutes. The average number of passes was 1.07 ± 0.258 in the holographic guidance group, compared with 2.33 ± 0.98 in the control group (p < 0.01). The mean target deviation was 4.34 ± 1.63 mm in the holographic guidance group and 11.26 ± 4.83 mm in the control group (p < 0.01).
This study demonstrates the use of a head-mounted mixed-reality holographic computer to successfully perform hologram-assisted bedside EVD insertion. A full set of clinically applicable workflow images is presented to show how medical imaging data can be used by the neurosurgeon to visualize patient-specific holograms that can intuitively guide hands-on operation. The authors also provide preliminary confirmation of the feasibility and accuracy of this hologram-guided EVD insertion technique.
Lei Xia, Hongwei Zhang, Chunjiang Yu, Mingshan Zhang, Ming Ren, Yanming Qu, Haoran Wang, Mingwang Zhu, Dianjiang Zhao, Xueling Qi and Kun Yao
The aim of this study was to evaluate the clinical results and surgical outcomes of cystic vestibular schwannomas (VSs) with fluid-fluid levels.
Forty-five patients with cystic VSs and 86 with solid VSs were enrolled in the study. The patients in the cystic VSs were further divided into those with and without fluid-fluid levels. The clinical and neuroimaging features, intraoperative findings, and surgical outcomes of the 3 groups were retrospectively compared.
Peritumoral adhesion was significantly greater in the fluid-level group (70.8%) than in the nonfluid-level group (28.6%) and the solid group (25.6%; p < 0.0001). Complete removal of the VS occurred significantly less in the fluid-level group (45.8%, 11/24) than in the nonfluid-level group (76.2%, 16/21) and the solid group (75.6%, 65/86; p = 0.015). Postoperative facial nerve function in the fluid-level group was less favorable than in the other 2 groups; good/satisfactory facial nerve function 1 year after surgery was noted in 50.0% cases in the fluid-level group compared with 83.3% cases in the nonfluid-level group (p = 0.038).
Cystic VSs with fluid-fluid levels more frequently adhered to surrounding neurovascular structures and had a less favorable surgical outcome. A possible mechanism of peritumoral adhesion is intratumoral hemorrhage and consequent inflammatory reactions that lead to destruction of the tumor-nerve barrier. These findings may be useful in predicting surgical outcome and planning surgical strategy preoperatively.
Yuan Wang, Bolin Liu, Tianzhi Zhao, Binfang Zhao, Daihua Yu, Xue Jiang, Lin Ye, Lanfu Zhao, Wenhai Lv, Yufu Zhang, Tao Zheng, Yafei Xue, Lei Chen, Eric Sankey, Long Chen, Yingxi Wu, Mingjuan Li, Lin Ma, Zhengmin Li, Ruigang Li, Juan Li, Jing Yan, Shasha Wang, Hui Zhao, Xude Sun, Guodong Gao, Yan Qu and Shiming He
Although enhanced recovery after surgery (ERAS) programs have gained acceptance in various surgical specialties, no established neurosurgical ERAS protocol for patients undergoing elective craniotomy has been reported in the literature. Here, the authors describe the design, implementation, safety, and efficacy of a novel neurosurgical ERAS protocol for elective craniotomy in a tertiary care medical center located in China.
A multidisciplinary neurosurgical ERAS protocol for elective craniotomy was developed based on the best available evidence. A total of 140 patients undergoing elective craniotomy between October 2016 and May 2017 were enrolled in a randomized clinical trial comparing this novel protocol to conventional neurosurgical perioperative management. The primary endpoint of this study was the postoperative hospital length of stay (LOS). Postoperative morbidity, perioperative complications, postoperative pain scores, postoperative nausea and vomiting, duration of urinary catheterization, time to first solid meal, and patient satisfaction were secondary endpoints.
The median postoperative hospital LOS (4 days) was significantly shorter with the incorporation of the ERAS protocol than that with conventional perioperative management (7 days, p < 0.0001). No 30-day readmission or reoperation occurred in either group. More patients in the ERAS group reported mild pain (visual analog scale score 1–3) on postoperative day 1 than those in the control group (79% vs. 33%, OR 7.49, 95% CI 3.51–15.99, p < 0.0001). Similarly, more patients in the ERAS group had a shortened duration of pain (1–2 days; 53% vs. 17%, OR 0.64, 95% CI 0.29–1.37, p = 0.0001). The urinary catheter was removed within 6 hours after surgery in 74% patients in the ERAS group (OR 400.1, 95% CI 23.56–6796, p < 0.0001). The time to first oral liquid intake was a median of 8 hours in the ERAS group compared to 11 hours in the control group (p < 0.0001), and solid food intake occurred at a median of 24 hours in the ERAS group compared to 72 hours in the control group (p < 0.0001).
This multidisciplinary, evidence-based, neurosurgical ERAS protocol for elective craniotomy appears to have significant benefits over conventional perioperative management. Implementation of ERAS is associated with a significant reduction in the postoperative hospital stay and an acceleration in recovery, without increasing complication rates related to elective craniotomy. Further evaluation of this protocol in large multicenter studies is warranted.
Clinical trial registration no.: ChiCTR-INR-16009662 (chictr.org.cn)