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Ashish Suri, Ravi Sharma, Varidh Katiyar, and Amol Raheja

Resection of petroclival meningiomas has remained challenging because of the critical neurovascular structures that lie in the vicinity, and thus various surgical corridors have been explored over time to figure out the optimum approach. In this video, the authors have highlighted the operative nuances of the modified Dolenc-Kawase (MDK) anterior petrous rhomboid approach. This approach gives access to the prepontine area, Dorello’s canal, anterior petrous apex, and upper two-thirds of the clivus with better angulation and surgical flexibility. It is a versatile approach for petroclival lesions that are not extending laterally and inferiorly to the internal auditory canal.

The video can be found here: https://stream.cadmore.media/r10.3171/2022.1.FOCVID21256

Free access

Ravi Sharma, Varidh Katiyar, Priya Narwal, Shashank S. Kale, and Ashish Suri

OBJECTIVE

The longer learning curve and smaller margin of error make nontraditional, or "out of operating room" simulation training, essential in neurosurgery. In this study, the authors propose an evaluation system for residents combining both task-based and procedure-based exercises and also present the perception of residents regarding its utility.

METHODS

Residents were evaluated using a combination of task-based and virtual reality (VR)–based exercises. The results were analyzed in terms of the seniority of the residents as well as their laboratory credits. Questionnaire-based feedback was sought from the residents regarding the utility of this evaluation system incorporating the VR-based exercises.

RESULTS

A total of 35 residents were included in this study and were divided into 3 groups according to seniority. There were 11 residents in groups 1 and 3 and 13 residents in group 2. On the overall assessment of microsuturing skills including both 4-0 and 10-0 microsuturing, the suturing skills of groups 2 and 3 were observed to be better than those of group 1 (p = 0.0014). Additionally, it was found that microsuturing scores improved significantly with the increasing laboratory credits (R2 = 0.72, p < 0.001), and this was found to be the most significant for group 1 residents (R2 = 0.85, p < 0.001). Group 3 residents performed significantly better than the other two groups in both straight (p = 0.02) and diagonal (p = 0.042) ring transfer tasks, but there was no significant difference between group 1 and group 2 residents (p = 0.35). Endoscopic evaluation points were also found to be positively correlated with previous laboratory training (p = 0.002); however, for the individual seniority groups, the correlation failed to reach statistical significance. The 3 seniority groups performed similarly in the cranial and spinal VR modules. Group 3 residents showed significant disagreement with the utility of the VR platform for improving surgical dexterity (p = 0.027) and improving the understanding of surgical procedures (p = 0.034). Similarly, there was greater disagreement for VR-based evaluation to identify target areas of improvement among the senior residents (groups 2 and 3), but it did not reach statistical significance (p = 0.194).

CONCLUSIONS

The combination of task- and procedure-based assessment of trainees using physical and VR simulation models can supplement the existing neurosurgery curriculum. The currently available VR-based simulations are useful in the early years of training, but they need significant improvement to offer beneficial learning opportunities to senior trainees.

Free access

Varidh Katiyar, Ravi Sharma, Vivek Tandon, Revanth Goda, Akshay Ganeshkumar, Ashish Suri, P. Sarat Chandra, and Shashank S. Kale

OBJECTIVE

The authors aimed to evaluate the impact of age and frailty on the surgical outcomes of patients with glioblastoma (GBM) and to assess caregivers’ perceptions regarding postdischarge care and challenges faced in the developing country of India.

METHODS

This was a retrospective study of patients with histopathologically proven GBM from 2009 to 2018. Data regarding the clinical and radiological characteristics as well as surgical outcomes were collected from the institute’s electronic database. Taking Indian demographics into account, the authors used the cutoff age of 60 years to define patients as elderly. Frailty was estimated using the 11-point modified frailty index (mFI-11). Patients were divided into three groups: robust, with an mFI score of 0; moderately frail, with an mFI score of 1 or 2; and severely frail, with an mFI score ≥ 3. A questionnaire-based survey was done to assess caregivers’ perceptions about postdischarge care.

RESULTS

Of the 276 patients, there were 93 (33.7%) elderly patients and 183 (66.3%) young or middle-aged patients. The proportion of severely frail patients was significantly more in the elderly group (38.7%) than in the young or middle-aged group (28.4%) (p < 0.001). The authors performed univariate and multivariate analysis of associations of different short-term outcomes with age, sex, frailty, and Charlson Comorbidity Index. On the multivariate analysis, only frailty was found to be a significant predictor for in-hospital mortality, postoperative complications, and length of hospital and ICU stay (p < 0.001). On Cox regression analysis, the severely frail group was found to have a significantly lower overall survival rate compared with the moderately frail (p = 0.001) and robust groups (p < 0.001). With the increase in frailty, there was a concomitant increase in the requirement for readmissions (p = 0.003), postdischarge specialist care (p = 0.001), and help from extrafamilial sources (p < 0.001). Greater dissatisfaction with psychosocial and financial support among the caregivers of severely frail patients was seen as they found themselves ill-equipped to provide postdischarge care at home (p < 0.001).

CONCLUSIONS

Frailty is a better predictor of poorer surgical outcomes than chronological age in terms of duration of hospital and ICU stay, postoperative complications, and in-hospital mortality. It also adds to the psychosocial and financial burdens of the caregivers, making postdischarge care challenging.

Free access

Amol Raheja, Shashwat Mishra, Kanwaljeet Garg, Varidh Katiyar, Ravi Sharma, Vivek Tandon, Revanth Goda, Ashish Suri, and Shashank S. Kale

OBJECTIVE

Extracorporeal telescopes (exoscopes) have been the latest addition to the neurosurgeons’ armamentarium, acting as a bridge between operating microscopes and endoscopes. However, to the authors’ knowledge there are no published preclinical laboratory studies of the accuracy, efficiency, and dexterity of neurosurgical training for the use of 2D or 3D exoscopes compared with microscopes.

METHODS

In a controlled experimental setup, 22 participating neurosurgery residents performed simple (2D) and complex (3D) motor tasks with three visualization tools in alternating sequence: a 2D exoscope, 3D exoscope, and microscope, using a block randomization model based on the neurosurgeons’ prior training experience (novice, intermediate, and senior: n = 6, 12, and 4, respectively). Performance scores (PS; including error and efficiency scores) and dexterity scores (DS) were calculated to objectify the accuracy, efficiency, and finesse of task performance. Repeated measures ANOVA analysis was used to compare the PS, DS, and cumulative scores (CS) of candidates using the three visualization aids. Bland-Altman plots and intraclass correlation coefficients were generated to quantify intraobserver and interobserver agreement for DS. Subgroup analysis was performed to assess the impact of participants’ prior training. A postexercise survey was conducted to assess the comfort level (on a 10-point analog scale) of the participants while using each visualization tool for performing the suturing task.

RESULTS

PS, DS, and CS were significantly impacted by the visualization tool utilized for 2D motor tasks (p < 0.001 for each), with the microscope faring better than the 2D exoscope (p = 0.04) or 3D exoscope (p = 0.008). The PS for the 3D object transfer task was significantly influenced by the visualization aid used (p = 0.007), with the microscope and 3D exoscope faring better than the 2D exoscope (p = 0.04 for both). The visualization instrument used significantly affected the DS and CS for the suturing task (p < 0.001 for both), with the microscope again scoring better than the 2D exoscope (p < 0.001) or 3D exoscope (p = 0.005). The impact of the visualization aid was more apparent in participants with a shorter duration of residency (novice, p = 0.03; intermediate, p = 0.0004). Participants also felt the greatest operational comfort while working with a microscope, 3D exoscope, and 2D exoscope, in that order (p < 0.0001).

CONCLUSIONS

Compared with 3D and 2D exoscopes, an operating microscope provides better dexterity and performance and a greater operational comfort level for neurosurgeons while they are performing 2D or 3D motor tasks. For performing complex 3D motor tasks, 3D exoscopes offer selective advantages in dexterity, performance, and operational comfort level over 2D exoscopes. The relative impact of visualization aids on surgical proficiency gradually weakens as the participants’ residency duration increases.

Free access

Narendra Kumar, Varidh Katiyar, Kokkula Praneeth, Ravi Sharma, Priya Narwal, Amol Raheja, Vivek Tandon, Shashwat Mishra, Kanwaljeet Garg, Ashish Suri, P. Sarat Chandra, and Shashank S. Kale

OBJECTIVE

The adoption of telemedicine became a necessity during the COVID-19 pandemic because patients found commuting to be difficult owing to travel restrictions. Initially, audio-based teleconsultations were provided. Later, on the basis of the feedback of patients and caregivers, the authors started to provide video-based teleconsultations via WhatsApp. The authors subsequently surveyed the patients and caregivers to determine their satisfaction levels with telemedicine services.

METHODS

An anonymized telephone survey of patients who had participated in teleconsultation was conducted with a structured questionnaire. The responses were analyzed and their correlations with the perceived benefits and limitations of audio and video teleconsultation were determined.

RESULTS

Three hundred respondents were included in the first round of surveys, of whom 250 (83.3%) consented to video teleconsultation. Among the respondents who participated in both audio and video teleconsultations (n = 250), paired analysis showed that video teleconsultation was perceived as better in terms of providing easier access to healthcare services (p < 0.001), saving time (p < 0.001), and satisfaction with the way patient needs were conveyed to healthcare providers (p = 0.023), as well as in terms of adequacy of addressing healthcare needs (p < 0.001) and consequently providing a higher rate of overall satisfaction (p < 0.001). For both audio and video teleconsultation, overall patient satisfaction was significantly related to only previous exposure to WhatsApp. However, for video consultation, longer call duration (p = 0.023) was an important independent factor. Video teleconsultation was preferable to face-to-face consultation irrespective of educational status, but higher education was associated with preference for video teleconsultation.

CONCLUSIONS

Both audio and video teleconsultation are viable cost-effective surrogates for in-person physical neurosurgical consultation. Although audio teleconsultation is more user-friendly and is not restricted by educational status, video teleconsultation trumps the former owing to a more efficient and satisfactory doctor-to-patient interface.

Restricted access

Intekhab Alam, Varidh Katiyar, Revanth Goda, Harish Chandrappa, Raghav Singla, and Ravi Sharma

Free access

Kanwaljeet Garg, Ravi Sharma, Amol Raheja, Vivek Tandon, Varidh Katiyar, Chinmaya Dash, Rishi Bhatnagar, Mohan Kumar Khullar, Bharath Raju, Anil Nanda, and Shashank S. Kale

OBJECTIVE

Despite the rising trend of medicolegal challenges in India, there is an absolute dearth of literature from India on this issue. The authors conducted a survey, to their knowledge a first of its kind, to assess the perceptions of Indian neurosurgeons about the medicolegal challenges faced in everyday practice.

METHODS

An anonymous online survey performed using Google Forms was widely circulated among neurosurgeons practicing in India via email and social media platforms. The questionnaire consisted of 38 questions covering the various aspects of medicolegal issues involved in neurosurgery practice.

RESULTS

A total of 221 survey responses were received, out of which 214 responses were included in the final analysis, barring 7 responders who had no work experience in India. The respondents were categorized according to their working arrangements and work experience. Out of all of the respondents, 20 (9.3%) had ≥ 1 malpractice suits filed against them. More than 90% of the respondents believed that malpractice suits are on the rise in India. Almost half of the respondents believed the advent of teleconsultation is further compounding the risk of malpractice suits, and 66.4% of respondents felt that they were inadequately trained during residency to deal with medicolegal issues. Most respondents (88.8%) felt that neurosurgeons working in the government sector had lesser chances of facing litigations in comparison to those working in the private sector. The practice of obtaining video proof of consent was more commonly reported by respondents working in freelancing and private settings (45.1%) and those with multiple affiliations (61.3%) compared to respondents practicing in government settings (22.8%) (p < 0.001). Neurosurgeons working in the private sector were more likely to alter management and refer sick patients to higher-volume treatment centers to avoid malpractice suits than their government counterparts (p = 0.043 and 0.006, respectively). The practices pertaining to legal preparedness were also found to be significantly higher among the respondents from the private sector (p < 0.001).

CONCLUSIONS

This survey highlights the apprehensions of neurosurgeons in India with regard to rising malpractice suits and the subsequent increase of defensive neurosurgical practices, especially in the private sector. A stronger legal framework for providing for quick redress of patient complaints, while deterring frivolous malpractice suits, can go a long way to allay these fears. There is a dire need for systematic training of neurosurgeons regarding legal preparedness, which should begin during residency.

Free access

Ravi Sharma, Revanth Goda, Sachin Anil Borkar, Varidh Katiyar, Samagra Agarwal, Amandeep Kumar, Sarita Mohapatra, Arti Kapil, Ashish Suri, and Shashank S. Kale

OBJECTIVE

The authors aimed to evaluate the antimicrobial susceptibility pattern of Acinetobacter isolates responsible for nosocomial meningitis/ventriculitis in the neurosurgical ICU. The authors also sought to identify the risk factors for mortality following Acinetobacter meningitis/ventriculitis.

METHODS

This was a retrospective study of 72 patients admitted to the neurosurgical ICU between January 2014 and December 2018 with clinical and microbiological diagnosis of nosocomial postneurosurgical Acinetobacter baumanii meningitis/ventriculitis. Electronic medical data on clinical characteristics, underlying pathology, CSF cytology, antibiotic susceptibilities, and mortality were recorded. To evaluate the outcome following nosocomial postneurosurgical Acinetobacter meningitis/ventriculitis, patients were followed up until discharge or death in the hospital. Kaplan-Meier survival analysis and multivariable Cox proportional hazards models were used to compute factors affecting survival.

RESULTS

The study population was divided into two groups depending on the final outcome of whether the patient died or survived. Forty-three patients (59.7%) were included in the survivor group and 29 patients (40.3%) were included in the nonsurvivor group. Total in-hospital mortality due to Acinetobacter meningitis/ventriculitis was 40.3% (29 cases), with a 14-day mortality of 15.3% and a 30-day mortality of 25%. The 43 (59.7%) patients who survived had a mean length of hospital stay of 44 ± 4 days with a median Glasgow Outcome Scale–Extended score at discharge of 6. On univariate analysis, age > 40 years (p = 0.078), admission Glasgow Coma Scale (GCS) score ≤ 8 (p = 0.003), presence of septic shock (p = 0.011), presence of external ventricular drain (EVD) (p = 0.03), CSF white blood cell (WBC) count > 200 cells/mm3 (p = 0.084), and comorbidities (diabetes, p = 0.036; hypertension, p = 0.01) were associated with poor outcome. Carbapenem resistance was not a risk factor for mortality. According to a multivariable Cox proportional hazards model, age cutoff of 40 years (p = 0.016, HR 3.21), GCS score cutoff of 8 (p = 0.006, HR 0.29), CSF WBC count > 200 cells/mm3 (p = 0.01, HR 2.76), presence of EVD (p = 0.001, HR 5.42), and comorbidities (p = 0.017, HR 2.8) were found to be significant risk factors for mortality.

CONCLUSIONS

This study is the largest case series reported to date of postneurosurgical Acinetobacter meningitis/ventriculitis. In-hospital mortality due to Acinetobacter meningitis/ventriculitis was high. Age older than 40 years, GCS score less than 8, presence of EVD, raised CSF WBC count, and presence of comorbidities were risk factors for mortality.