Boosting teamwork between scrub nurses and neurosurgeons: exploring the value of a role-played hands-on, cadaver-free simulation and systematic review of the literature

Background

Recently, non-technical skills (NTS) and teamwork in particular have been demonstrated to be essential in many jobs, in business as well as in medical specialties, including plastic, orthopedic, and general surgery. However, NTS and teamwork in neurosurgery have not yet been fully studied. We reviewed the relevant literature and designed a mock surgery to be used as a team-building activity specifically designed for scrub nurses and neurosurgeons.

Methods

We conducted a systematic review by searching PubMed (Medline) and CINAHL, including relevant articles in English published until 15 July 2023. Then, we proposed a pilot study consisting of a single-session, hands-on, and cadaver-free activity, based on role play. Scrub nurses were administered the SPLINTS (Scrub Practitioners' List of Intraoperative Non-Technical Skills) rating form as a self-evaluation at baseline and 20-30 days after the simulation. During the experiment, surgeons and scrub nurses role-played as each other, doing exercises including a simulated glioma resection surgery performed on an advanced model of a cerebral tumor (Tumor Box, UpSurgeOn®) under an exoscope. At the end, every participant completed an evaluation questionnaire.

Results

A limited number of articles are available on the topic. This study reports one of the first neurosurgical team-building activities in the literature. All the participating scrub nurses and neurosurgeons positively evaluated the simulation developed on a roleplay. The use of a physical simulator seems an added value, as the tactile feedback given by the model further helps to understand the actual surgical job, more than only observing and assisting. The SPLINTS showed a statistically significant improvement not only in "Communication and Teamwork" (p = 0.048) but also in "Situation Awareness" (p = 0.031).

Conclusion

Our study suggests that team-building activities may play a role in improving interprofessional teamwork and other NTS in neurosurgery.

Reducing the Gap in Neurosurgical Education in LMICs: A Report of a Non-Profit Educational Program

INTRODUCTION

Central to neurosurgical care, neurosurgical education is particularly needed in low- and middle-income countries (LMICs), where opportunities for neurosurgical training are limited due to social and economic constraints and an inadequate workforce. The present paper aims (1) to evaluate the validity and usability of a cadaver-free hybrid system in the context of LMICs and (2) to report their learning needs and whether the courses meet those needs via a comprehensive survey.

METHODS

From April to November 2021, a non-profit initiative consisting of a series of innovative cadaver-free courses based on virtual and practical training was organized. This project emerged from a collaboration between the Young Neurosurgeons Forum of the World Federation of Neurological Societies (WFNS), the NIHR Global Health Research Group on Neurotrauma, and UpSurgeOn, an Italian hi-tech company specialized in simulation technologies, creator of the UpSurgeOn Box, a hyper-realistic simulator of cranial approaches fused with augmented reality. Over that period, 11 cadaver-free courses were held in LMICs using remote hands-on Box simulators.

RESULTS

One hundred sixty-eight participants completed an online survey after course completion of the course. The anatomical accuracy of simulators was overall rated high by the participant. The simulator provided a challenging but manageable learning curve, and 86% of participants found the Box to be very intuitive to use. When asked if the sequence of mental training (app), hybrid training (Augmented Reality), and manual training (the Box) was an effective method of training to fill the gap between theoretical knowledge and practice on a real patient/cadaver, 83% of participants agreed. Overall, the hands-on activities on the simulators have been satisfactory, as well as the integration between physical and digital simulation.

CONCLUSIONS

This project demonstrated that a cadaver-free hybrid (virtual/hands-on) training system could potentially participate in accelerating the learning curve of neurosurgical residents, especially in the setting of limited training possibilities such as LMICs, which were only worsened during the COVID-19 pandemic.

Applying objective metrics to neurosurgical skill development with simulation and spaced repetition learning

OBJECTIVE

Surgical skills laboratories augment educational training by deepening one's understanding of anatomy and allowing the safe practice of technical skills. Novel, high-fidelity, cadaver-free simulators provide an opportunity to increase access to skills laboratory training. The neurosurgical field has historically evaluated skill by subjective assessment or outcome measures, as opposed to process measures with objective, quantitative indicators of technical skill and progression. The authors conducted a pilot training module with spaced repetition learning concepts to evaluate its feasibility and impact on proficiency.

METHODS

The 6-week module used a simulator of a pterional approach representing skull, dura mater, cranial nerves, and arteries (UpSurgeOn S.r.l.). Neurosurgery residents at an academic tertiary hospital completed a video-recorded baseline examination, performing supraorbital and pterional craniotomies, dural opening, suturing, and anatomical identification under a microscope. Participation in the full 6-week module was voluntary, which precluded randomizing by class year. The intervention group participated in four additional faculty-guided trainings. In the 6th week, all residents (intervention and control) repeated the initial examination with video recording. Videos were evaluated by three neurosurgical attendings who were not affiliated with the institution and who were blinded to participant grouping and year. Scores were assigned via Global Rating Scales (GRSs) and Task-based Specific Checklists (TSCs) previously built for craniotomy (cGRS, cTSC) and microsurgical exploration (mGRS, mTSC).

RESULTS

Fifteen residents participated (8 intervention, 7 control). The intervention group included a greater number of junior residents (postgraduate years 1-3; 7/8) compared to the control group (1/7). External evaluators had internal consistency within 0.5% (kappa probability > Z of 0.00001). The total average time improved by 5:42 minutes (p < 0.003; intervention, 6:05, p = 0.07; control, 5:15, p = 0.001). The intervention group began with lower scores in all categories and surpassed the comparison group in cGRS (10.93 to 13.6/16) and cTSC (4.0 to 7.4/10). Percent improvements for the intervention group were cGRS 25% (p = 0.02), cTSC 84% (p = 0.002), mGRS 18% (p = 0.003), and mTSC 52% (p = 0.037). For controls, improvements were cGRS 4% (p = 0.19), cTSC 0.0% (p > 0.99), mGRS 6% (p = 0.07), and mTSC 31% (p = 0.029).

CONCLUSIONS

Participants who underwent a 6-week simulation course showed significant objective improvement in technical indicators, particularly individuals who were early in their training. Small, nonrandomized grouping limits generalizability regarding degree of impact; however, introducing objective performance metrics during spaced repetition simulation would undoubtedly improve training. A larger multiinstitutional randomized controlled study will help elucidate the value of this educational method.

Benchtop simulation of the retrosigmoid approach: Validation of a surgical simulator and development of a task-specific outcome measure score

Background

Neurosurgical training is changing globally. Reduced working hours and training opportunities, increased patient safety expectations, and the impact of COVID-19 have reduced operative exposure. Benchtop simulators enable trainees to develop surgical skills in a controlled environment. We aim to validate a high-fidelity simulator model (RetrosigmoidBox, UpSurgeOn) for the retrosigmoid approach to the cerebellopontine angle (CPA).

Methods

Novice and expert Neurosurgeons and Ear, Nose, and Throat surgeons performed a surgical task using the model - identification of the trigeminal nerve. Experts completed a post-task questionnaire examining face and content validity. Construct validity was assessed through scoring of operative videos employing Objective Structured Assessment of Technical Skills (OSATS) and a novel Task-Specific Outcome Measure score.

Results

Fifteen novice and five expert participants were recruited. Forty percent of experts agreed or strongly agreed that the brain tissue looked real. Experts unanimously agreed that the RetrosigmoidBox was appropriate for teaching. Statistically significant differences were noted in task performance between novices and experts, demonstrating construct validity. Median total OSATS score was 14/25 (IQR 10-19) for novices and 22/25 (IQR 20-22) for experts (p < 0.05). Median Task-Specific Outcome Measure score was 10/20 (IQR 7-17) for novices compared to 19/20 (IQR 18.5-19.5) for experts (p < 0.05).

Conclusion

The RetrosigmoidBox benchtop simulator has a high degree of content and construct validity and moderate face validity. The changing landscape of neurosurgical training mean that simulators are likely to become increasingly important in the delivery of high-quality education. We demonstrate the validity of a Task-Specific Outcome Measure score for performance assessment of a simulated approach to the CPA.

Needs, Roles and Challenges of Young Asian Neurosurgeons

BACKGROUND

Asia has a marked shortage of neurosurgical care, with approximately 2.5 million critical cases left untreated. The Young Neurosurgeons Forum (YNF) of the World Federation of Neurosurgical Societies (WFNS) surveyed Asian neurosurgeons to identify the of research, education, and practice.

METHODS

A cross-sectional study using a pilot-tested e-survey was circulated to the Asian neurosurgical community from April to November 2018. Descriptive statistics were used to summarize variables pertaining to demographics and neurosurgical practices. Chi square test was utilized to explore the relation between World Bank income level and variables on neurosurgical practices.

RESULTS

A total of 242 responses were analyzed. Respondents were mostly from the low- and middle-income countries (70%). Most represented institutions were teaching hospitals (53%). >50% of the hospitals had between 25-50 neurosurgical beds. Access to an operating microscope (p=0.038) or image guidance system (p=0.001) appeared to increase in correlation to a higher World Bank income level. Limited opportunities for conducting research (56%) and hands-on operating opportunities (45%) were leading challenges in daily academic practice. The leading challenges were limited numbers of intensive care unit beds (51%), inadequate or absent insurance coverage (45%), and lack of organized peri-hospital care (43%). Inadequate insurance coverage decreased with increasing World Bank income levels (p<0.001). Organized peri-hospital care (p=0.001), regular MRI access (p=0.032), and equipment necessary for microsurgery (p=0.007) increased with higher World Bank income levels.

CONCLUSION

Improving neurosurgical care hinges on regional and international collaboration and national policies to ensure universal access to essential neurosurgical care.

Exoscope and operative microscope for training in microneurosurgery: A laboratory investigation on a model of cranial approach

Objective

To evaluate the viability of exoscopes in the context of neurosurgical education and compare the use of a 4k3D exoscope to a traditional operative microscope in the execution of a task of anatomic structure identification on a model of cranial approach.

Material and methods

A cohort of volunteer residents performed a task of anatomical structure identification with both devices three times across an experimental period of 2 months. We timed the residents’ performances, and the times achieved were analyzed. The volunteers answered two questionnaires concerning their opinions of the two devices.

Results

Across tries, execution speed improved for the whole cohort. When using the exoscopes, residents were quicker to identify a single anatomical structure starting from outside the surgical field when deep structures were included in the pool. In all other settings, the two devices did not differ in a statistically significant manner. The volunteers described the exoscope as superior to the microscope in all the aspects the questionnaires inquired about, besides the depth of field perception, which was felt to be better with the microscope. Volunteers furthermore showed overwhelming support for training on different devices and with models of surgical approaches.

Conclusion

The exoscope appeared to be non-inferior to the microscope in the execution of a task of timed identification of anatomical structures on a model of cranial approach carried out by our cohort of residents. In the questionnaires, the residents reported the exoscope to be superior to the microscope in eight of nine investigated domains. Further studies are needed to investigate the use of the exoscope in learning of microsurgical skills.

High fidelity simulation of the endoscopic transsphenoidal approach: Validation of the UpSurgeOn TNS Box

Objective

Endoscopic endonasal transsphenoidal surgery is an established technique for the resection of sellar and suprasellar lesions. The approach is technically challenging and has a steep learning curve. Simulation is a growing training tool, allowing the acquisition of technical skills pre-clinically and potentially resulting in a shorter clinical learning curve. We sought validation of the UpSurgeOn Transsphenoidal (TNS) Box for the endoscopic endonasal transsphenoidal approach to the pituitary fossa.

Methods

Novice, intermediate and expert neurosurgeons were recruited from multiple centres. Participants were asked to perform a sphenoidotomy using the TNS model. Face and content validity were evaluated using a post-task questionnaire. Construct validity was assessed through post-hoc blinded scoring of operative videos using a Modified Objective Structured Assessment of Technical Skills (mOSAT) and a Task-Specific Technical Skill scoring system.

Results

Fifteen participants were recruited of which n = 10 (66.6%) were novices and n = 5 (33.3%) were intermediate and expert neurosurgeons. Three intermediate and experts (60%) agreed that the model was realistic. All intermediate and experts (n = 5) strongly agreed or agreed that the TNS model was useful for teaching the endonasal transsphenoidal approach to the pituitary fossa. The consensus-derived mOSAT score was 16/30 (IQR 14-16.75) for novices and 29/30 (IQR 27-29) for intermediate and experts (p < 0.001, Mann-Whitney U). The median Task-Specific Technical Skill score was 10/20 (IQR 8.25-13) for novices and 18/20 (IQR 17.75-19) for intermediate and experts (p < 0.001, Mann-Whitney U). Interrater reliability was 0.949 (CI 0.983-0.853) for OSATS and 0.945 (CI 0.981-0.842) for Task-Specific Technical Skills. Suggested improvements for the model included the addition of neuro-vascular anatomy and arachnoid mater to simulate bleeding vessels and CSF leak, respectively, as well as improvement in materials to reproduce the consistency closer to that of human tissue and bone.

Conclusion

The TNS Box simulation model has demonstrated face, content, and construct validity as a simulator for the endoscopic endonasal transsphenoidal approach. With the steep learning curve associated with endoscopic approaches, this simulation model has the potential as a valuable training tool in neurosurgery with further improvements including advancing simulation materials, dynamic models (e.g., with blood flow) and synergy with complementary technologies (e.g., artificial intelligence and augmented reality).

Virtual-Augmented Reality and Life-Like Neurosurgical Simulator for Training: First Evaluation of a Hands-On Experience for Residents

Background

In the recent years, growing interest in simulation-based surgical education has led to various practical alternatives for medical training. More recently, courses based on virtual reality (VR) and three-dimensional (3D)-printed models are available. In this paper, a hybrid (virtual and physical) neurosurgical simulator has been validated, equipped with augmented reality (AR) capabilities that can be used repeatedly to increase familiarity and improve the technical skills in human brain anatomy and neurosurgical approaches.

Methods

The neurosurgical simulator used in this study (UpSurgeOn Box, UpSurgeOn Srl, Assago, Milan) combines a virtual component and a physical component with an intermediate step to provide a hybrid solution. A first reported and evaluated practical experience on the anatomical 3D-printed model has been conducted with a total of 30 residents in neurosurgery. The residents had the possibility to choose a specific approach, focus on the correct patient positioning, and go over the chosen approach step-by-step, interacting with the model through AR application. Next, each practical surgical step on the 3D model was timed and qualitatively evaluated by 3 senior neurosurgeons. Quality and usability-grade surveys were filled out by participants.

Results

More than 89% of the residents assessed that the application and the AR simulator were very helpful in improving the orientation skills during neurosurgical approaches. Indeed, 89.3% of participants found brain and skull anatomy highly realistic during their tasks. Moreover, workshop exercises were considered useful in increasing the competency and technical skills required in the operating room by 85.8 and 84.7% of residents, respectively. Data collected confirmed that the anatomical model and its application were intuitive, well-integrated, and easy to use.

Conclusion

The hybrid AR and 3D-printed neurosurgical simulator could be a valid tool for neurosurgical training, capable of enhancing personal technical skills and competence. In addition, it could be easy to imagine how patient safety would increase and healthcare costs would be reduced, even if more studies are needed to investigate these aspects. The integration of simulators for training in neurosurgery as preparatory steps for the operating room should be recommended and further investigated given their huge potential.

Tentorial Notch Meningiomas: Innovative Preoperative Management and Literature Review

Background

Tentorial meningiomas account for only 3–6% of all intracranial meningiomas. Among them, tentorial incisura (notch) location must be considered as a subgroup with specific surgical anatomy and indications, morbidity, and mortality. In this study, we propose an update on preoperative management in order to reduce postoperative deficits.

Methods

We retrospectively collected adult patients treated for incisural meningioma between January 1992 and December 2016 in two different neurosurgical departments. Demographic, clinical, and neuroradiological preoperative and postoperative data were analyzed. In the most recent subgroup of tumors, a preoperative digital simulation was performed to define a volumetric digital quantification of the tumor resection. A review of the pertinent literature has been also done.

Results

We included 26 patients. The median age was 58.4 years. Onset neurological signs were cranial nerve deficit in 9 patients, hemiparesis in 7, gait disturbance in 3, and intracranial hypertension in 3 patients. Simpson grade I removal was achieved in 12 patients, II in 10, III in 3, and IV in 1 patient. An overall rate of 23% postoperative complications was observed. The average follow-up duration was 68.5 months. Residual tumor was reported in 8 patients. Five patients underwent gamma knife radiosurgery. In 34.6% of patients, the surgical approach was chosen with preoperative digital planning estimating the potential volume of postoperative residual tumor, the target for radiosurgical treatment.

Conclusions

A multidisciplinary approach to plan incisural meningiomas management is important. To lower postoperative morbidity and mortality, a careful preoperative case analysis is useful. A planned residual tumor, supported by preoperative simulation imaging, could be safely treated with radiosurgery.

Minimally Invasive Subfrontal Approach: How to Make it Safe and Effective from the Olfactory Groove to the Mesial Temporal Lobe

BACKGROUND

 Different surgical approaches have been developed to manage lesions of the anterior and middle skull base areas. Frontal, pterional, bifrontal, and fronto-orbito-zygomatic approaches are traditionally used to reach these regions. With advancements in the neurosurgical field, skull opening should be simple and as minimally invasive as possible, tailored on the surgical corridor to the target. The supraorbital approach and the "keyhole" concept have been introduced and popularized by Axel Perneczky starting from 1998 and are now considered a part of everyday practice. The extended possibilities of this surgical route, considering the reachable targets and surgical limits, are described and systematically analyzed, including a description of the salient surgical anatomy, presenting different illustrative cases.

METHODS AND RESULTS

 Different illustrative cases are presented and discussed to underline the potentials and limits of the minimally invasive subfrontal approach (MISFA) and the possibilities to tailoring the craniotomy on the basis of the targets: extra-axial lesions with different localizations (anterior roof of the orbit, olfactory groove, tuberculum sellae, medial third of the sphenoid wing, anterior and posterior clinoid process), deeper intra-axial lesions (gyrus rectus, medial temporal lobe-uncus-amygdala-anterior hippocampus), and vascular lesions (anterior communicating aneurysm). Each case has been preoperatively planned considering the anatomical and radiologic features and using virtual simulation software to tailor the best possible corridor to reach the surgical target.

CONCLUSIONS

 The MISFA is a safe multicorridor approach that can be used efficiently to manage lesions of the anterior and middle skull base areas with extremely low approach-related morbidity.

The World Federation of Neurosurgical Societies Young Neurosurgeons Survey (Part II): Barriers to Professional Development and Service Delivery in Neurosurgery

BACKGROUND

Strengthening health systems requires attention to workforce, training needs, and barriers to service delivery. The World Federation of Neurosurgical Societies Young Neurosurgeons Committee survey sought to identify challenges for residents, fellows, and consultants within 10 years of training.

METHODS

An online survey was distributed to various neurosurgical societies, personal contacts, and social media platforms (April-November 2018). Responses were grouped by World Bank income classification into high-income countries (HICs), upper middle-income countries (UMICs), low-middle-income countries (LMICs), and low-income countries (LICs). Descriptive statistical analysis was performed.

RESULTS

In total, 953 individuals completed the survey. For service delivery, the limited number of trained neurosurgeons was seen as a barrier for 12.5%, 29.8%, 69.2%, and 23.9% of respondents from HICs, UMICs, LMICs, and LICs, respectively (P < 0.0001). The most reported personal challenge was the lack of opportunities for research (HICs, 34.6%; UMICs, 57.5%; LMICs, 61.6%; and LICs, 61.5%; P = 0.03). Other differences by income class included limited access to advice from experienced/senior colleagues (P < 0.001), neurosurgical journals (P < 0.0001), and textbooks (P = 0.02). Assessing how the World Federation of Neurosurgical Societies could best help young neurosurgeons, the most frequent requests (n = 953; 1673 requests) were research (n = 384), education (n = 296), and subspecialty/fellowship training (n = 232). Skills courses and access to cadaver dissection laboratories were also heavily requested.

CONCLUSIONS

Young neurosurgeons perceived that additional neurosurgeons are needed globally, especially in LICs and LMICs, and primarily requested additional resources for research and subspecialty training.

The World Federation of Neurosurgical Societies Young Neurosurgeons Survey (Part I): Demographics, Resources, and Education

BACKGROUND

Providing a comprehensive and effective neurosurgical service requires adequate numbers of well-trained, resourced, and motivated neurosurgeons. The survey aims to better understand 1) the demographics of young neurosurgeons worldwide; 2) the challenges in training and resources that they face; 3) perceived barriers; and 4) needs for development.

METHODS

This was a cross-sectional study in which a widely disseminated online survey (April 2018-November 2019) was used to procure a nonprobabilistic sample from current neurosurgical trainees and those within 10 years of training. Data were grouped by World Bank income classifications and analyzed using χ2 tests because of its categorical nature.

RESULTS

There were 1294 respondents, with 953 completed responses included in the analysis. Of respondents, 45.2% were from high-income countries (HICs), 23.2% from upper-middle-income countries, 26.8% lower-middle-income countries, and 4.1% from low-income countries. Most respondents (79.8%) were male, a figure more pronounced in lower-income groups. Neuro-oncology was the most popular in HICs and spinal surgery in all other groups. Although access to computed tomography scanning was near universal (98.64%), magnetic resonance imaging access decreased to 66.67% in low-income countries, compared with 98.61% in HICs. Similar patterns were noted with access to operating microscopes, image guidance systems, and high-speed drills. Of respondents, 71.4% had dedicated time for neurosurgical education.

CONCLUSIONS

These data confirm and quantify disparities in the equipment and training opportunities among young neurosurgeons practicing in different income groups. We hope that this study will act as a guide to further understand these differences and target resources to remedy them.

The History of Decompressive Craniectomy in Traumatic Brain Injury

Decompressive craniectomy consists of removal of piece of bone of the skull in order to reduce intracranial pressure. It is an age-old procedure, taking ancient roots from the Egyptians and Romans, passing through the experience of Berengario da Carpi, until Theodore Kocher, who was the first to systematically describe this procedure in traumatic brain injury (TBI). In the last century, many neurosurgeons have reported their experience, using different techniques of decompressive craniectomy following head trauma, with conflicting results. It is thanks to the successes and failures reported by these authors that we are now able to better understand the pathophysiology of brain swelling in head trauma and the role of decompressive craniectomy in mitigating intracranial hypertension and its impact on clinical outcome. Following a historical description, we will describe the steps that led to the conception of the recent randomized clinical trials, which have taught us that decompressive craniectomy is still a last-tier measure, and decisions to recommend it should been made not only according to clinical indications but also after consideration of patients' preferences and quality of life expectations.

Real-Time Ex-Vivo Magnetic Resonance Image-Guided Dissection of Human Brain White Matter: A Proof-of-Principle Study

OBJECTIVE

Modern neuroanatomic education should be based on interdisciplinary methods that allow an understanding of the cerebral circuitry, which is at the base of the structural connectivity. Ex-vivo MRI-guided dissection is an essential method for developing and refining the knowledge of complex 3-dimensional brain anatomy and the mutual relationships between structures and architecture of the white matter bundles. The aim of this technical note is to present a new and innovative method of studying human brain white matter.

METHODS

Four adult human cerebral hemispheres were prepared according to the Klinger's method. T1-weighted and T2-weighted and fluid attenuated inversion recovery images were obtained with a 3T magnetic resonance machine. The dissection was performed in a dedicated neurosurgical laboratory equipped with a microscope and an electromagnetic neuronavigation system that guided the whole white matter dissection.

RESULTS

Gyri and sulci morphology were studied in detail. The relations between superficial and inner structures were observed before and after the dissection. Gray matter was carefully removed with blunt dissectors, and the U-fibers were exposed. Afterwards, deeper association and projection fibers, such as the arcuate fasciculus, superior and inferior longitudinal fasciculus, corona radiata, extreme and external capsule, claustrum, anterior commissure, and internal capsule were visualized under high magnification. The neuronavigation system was crucial for continuously checking the whole dissection procedure to avoid any accidental excision of fibers.

CONCLUSION

Image-guided neuronavigated dissection can significantly improve the quality of white matter dissection and represents a valid tool for learning the 3-dimensional anatomy of the human brain tracts.

Epidemiology of severe traumatic brain injury

About 5.48 million people are estimated to suffer from severe traumatic brain injury (TBI) each year (73 cases per 100,000 people). The WHO estimates that almost 90% of deaths due to injuries occur in low- and middle-income countries (LMICs), where the 85% of population live. Of these trauma-related deaths TBI is the main cause of one-third to one-half and represents the greatest cause of death and disability globally among all trauma-related injuries. The primary causes of TBI vary by age, socioeconomic factors, and geographic region, so any planned interventions must take in account this variability. The road traffic injuries (RTI) scenario is still strictly connected to the analysis of the global incidence of TBI, and to the reason why the LMICs experience nearly 3 times as many cases of TBI proportionally than high-income countries (HICs). The proportion of TBIs resulting from road traffic collisions was greatest in Africa and Southeast Asia (both 56%) and lowest in North America (25%). In HICs, falls and RTIs were reported most frequently as cause of TBI, but the traumas attributable to RTIs dropped from 39% in 2003 to 24% in 2012, while those attributable to falls increased from 43% to 54% respectively, with an increase TBI in the elderly (>65 years) due to falls. Differently from HICs, the population with the peak of TBI incidence is younger in LMICs, with an age between 28.8 and 33.1, as extensively reported. The burden of disease is significant; between 1,730,000 and 1,965,000 lives could be saved if global trauma care were improved in LMICs. Clinical practice recommendation should be developed and created in environments where the severe TBI mainly occurs. The applicability of high-income-country clinical research standards in LMICs is an important topic for future international research.

Calcifying aponeurotic fibroma: a core biopsy-based diagnosis

Calcifying aponeurotic fibroma (CAF) is a very rare tumor of the extremities, which can be difficult to diagnose due to its wide cyto-architectural pattern. We herein report the clinicopathologic features of a case of CAF localized on the dorsal face of the foot in a 5-year-old male child, diagnosed by needle core biopsy. Differential diagnostic problems are discussed. The present case emphasizes that the diagnosis of CAF can be confidentially rendered on core needle biopsy if the main morphological components of this tumor are concurrently present; however, before making the diagnosis of CAF, the clinical and radiological context should be considered.

Neurosurgical digital teaching in low-middle income countries: beyond the frontiers of traditional education

OBJECTIVE

Neurosurgical training is usually based on traditional sources of education, such as papers, books, direct surgical experience, and cadaveric hands-on courses. In low-middle income countries, standard education programs are often unavailable, mainly owing to the lack of human and economic resources. Introducing digital platforms in these settings could be an alternative solution for bridging the gap between Western and poor countries in neurosurgical knowledge.

METHODS

The authors identified from the Internet the main digital platforms that could easily be adopted in low-middle income countries. They selected free/low-cost mobile content with high educational impact.

RESULTS

The platforms that were identified as fulfilling the characteristics described above are WFNS Young Neurosurgeons Forum Stream, Brainbook, NeuroMind, UpSurgeOn, The Neurosurgical Atlas, Touch surgery, The 100 UCLA Subjects in Neurosurgery, Neurosurgery Survival Guide, EANS (European Association of Neurosurgical Societies) Academy, Neurosurgical.TV, 3D Neuroanatomy, The Rhoton Collection, and Hinari. These platforms consist of webinars, 3D interactive neuroanatomy and neurosurgery content, videos, and e-learning programs supported by neurosurgical associations or journals.

CONCLUSIONS

Digital education is an emerging tool for contributing to the spread of information in the neurosurgical community. The continuous improvement in the quality of content will rapidly increase the scientific validity of digital programs. In conclusion, the fast and easy access to digital resources could contribute to promote neurosurgical education in countries with limited facilities.

Endoscopic Transseptal Approach with Posterior Nasal Spine Removal: A Wide Surgical Corridor to the Craniovertebral Junction and Odontoid: Technical Note and Case Series

BACKGROUND

The transnasal approach to lesions involving the craniovertebral junction represents a technical challenge because of limited inferior exposure. The endoscopic transseptal approach (EtsA) with posterior nasal spine (PNS) removal is described. This technique can create a wide exposure of the craniovertebral junction, thereby increasing the caudal exposure.

METHODS

On patients undergoing anterior craniovertebral junction decompression, we calculated the degree of exposure on the sagittal plan through a paraseptal route, an EtsA without and with PNS removal. The horizontal exposure and working area with the latter approach were also evaluated.

RESULTS

Five patients underwent the transnasal procedure. The age of patients ranged from 34-71 years. All patients harbored basilar impression. The mean postoperative Nurick grade (1, 8) was improved versus the average preoperative grade (3). The average follow-up duration was 16 months. All patients underwent occipitocervical fixation. The mean vertical distances, from the clinoid recess to the inferior most limit with the paraseptal approach, EtsA without and with PNS removal were 38.52, 44.12, and 51.16 mm, respectively. The difference between our approach and a standard paraseptal route was statistically significant (P = 0.041; P< 0.05). The mean horizontal distances were 31.68 mm (mononostril entry) and 35.37 mm (binostril entry). The mean working area was 1795.53 mm².

CONCLUSIONS

Endoscopic endonasal approaches to the craniovertebral junction are increasing, but the downward extension on the anterior cervical spine represents a limit. Therefore, many surgeons prefer transoral or transcervical approaches. The EtsA with PNS removal allows for a more caudal exposure than the standard paraseptal approach, with reduced nasal trauma.

Safety and Feasibility of Salvage Endoscopic Combined Intrarenal Surgery in Embolized Kidney

Background: Although endoscopic combined intrarenal surgery (ECIRS) is well established as primary approach to complex lithiasis, no evidences are still available on its use in salvage context.

Case Presentation: A male patient, of 55 years of age, underwent many unsuccessful surgical procedures to treat large and multiple right kidney stones, including percutaneous nephrolithotomy (PCNL). The latter was complicated by severe postoperative hemorrhage, managed with super-selective renal artery embolization (SRAE). Therefore he came to our institution to achieve a complete resolution of the urolithiasis. Preoperative evaluation included CT scan and renal scintigraphy to establish kidney and stone morphologic features and residual renal function. Salvage ECIRS was performed and postoperative assessment showed a complete resolution of lithiasis and absence of renal function impairment.

Conclusion: To our knowledge, this is the first case of salvage ECIRS reported in literature after previous failed PCNL. Even after SRAE, this procedure appears as safe and as efficacious as standard salvage PCNL when performed by experienced hands.

Hydroperitoneum: A Rare Complication Performing Endoscopic Combined Intrarenal Surgery

Background: Recently endoscopic combined intrarenal surgery (ECIRS) has been introduced as an innovative approach for the treatment of complex single, multiple, and staghorn urolithiasis, which reveals to be a viable alternative to standard percutaneous nephrolithotomy. Although considered to be a versatile, safe, and efficient endoscopic procedure, it is not free from complications. We would like to report two rare cases of hydroperitoneum that occurred during ECIRS and their management.

Case Presentation: Two female patients, respectively, of 75 and 41 years of age, underwent ECIRS procedure for the treatment of complex staghorn kidney urolithiasis, previously evaluated by noncontrast computed tomography (CT) scan. A combined retrograde-percutaneous access to the intrarenal collecting system, under fluoroscopic and ultrasound guidance with the additional assistance of Endovision technique, was performed. At the end of the procedures, both patients revealed a taut and globous abdomen, and a perioperative CT and ultrasonography revealed the presence of intraperitoneal liquid. Both patients were effectively treated with immediate positioning of abdominal drain with rapid improvement of the clinical presentation.

Conclusion: To our knowledge these are the first two cases of hydroperitoneum occurring during ECIRS and reported in the literature. An early detection of the complication and its prompt treatment revealed to be crucial to effectively prevent morbidity.

The carboxyl-terminal region is NOT essential for secreted and functional levels of coagulation factor X

BACKGROUND

The homologous coagulation factor X (FX), VII (FVII), IX (FIX) and protein C (PC) display striking differences in the carboxyl-terminus, with that of FX being the most extended. This region is essential for FVII, FIX and PC secretion.

OBJECTIVES

To provide experimental evidence for the role of the FX carboxyl-terminus.

METHODS

Recombinant FX (rFX) variants were expressed in multiple eukaryotic cell systems. Protein and activity levels were evaluated by ELISA, coagulant and amidolytic assays.

RESULTS AND DISCUSSION

Expression of a panel of progressively truncated rFX variants in HEK293 cells revealed that the deletion of up to 21 residues in the carboxyl-terminus did not significantly affect secreted protein levels, as confirmed in HepG2 and BHK21 cells. In contrast, chimeric rFX-FVII variants with swapped terminal residues showed severely reduced levels. The truncated rFX variants revealed normal amidolytic activity, suggesting an intact active site. Intriguingly, these variants, which included that resembling the activated FXβ form once cleaved, also displayed remarkable or normal pro-coagulant capacity in PT- and aPTT-based assays. This supports the hypothesis that subjects with nonsense mutations in the FX carboxyl-terminus, so far never identified, would be asymptomatic.

CONCLUSIONS

For the first time we demonstrate that the FX carboxyl-terminal region downstream of residue K467 is not essential for secretion and provides a modest contribution to pro-coagulant properties. These findings, which might suggest an involvement of the carboxyl-terminal region in the divergence of the homologous FX, FVII, FIX and PC, help to interpret the mutational pattern of FX deficiency.

Can neck swelling lead to spinal cord compression?

Spinal cord compression (SCC) caused by cervical spinal canal invasion of a pulmonary sarcomatoid carcinoma metastasis has never been reported previously. A 59-year-old man, with a history of pulmonary carcinosarcoma, developed over several weeks important neck swelling. Admitted to our division with severe tetraparesis he underwent a cervical spine computed tomography scan that showed a large cervical mass measuring 11 cm × 27 cm × 17 cm with SCC, extending from the occiput to C7. Emergency spinal cord decompression was performed leading to minor neurological improvement. Poor outcome was due to the unusual clinical sign that led to late diagnosis and treatment.

Results at 48 Months of a Randomized Trial on Maintenance after Early Adjuvant

Introduction and objectives

The role of maintenance regimen following early intravesical chemotherapy after TUR of intermediate risk non-muscle invasive bladder cancer (NMI-BC) is still debated. Only few studies have been published on this topic, rarely dealing with patients receiving an early treatment. The aim of the present study is to evaluate the efficacy of one-year maintenance after a 6-week cycle of early intravesical chemotherapy.

Methods

Between May 2002 and August 2003, 482 patients with intermediate risk NMI-BC after TUR and early intravesical chemotherapy (epirubicin, 80mg/50mL) were randomized between 6-week induction cycle and induction plus maintenance with 10 monthly instillations. A written informed consent was obtained. All patients underwent cytology and cystoscopy 3-monthly for 2 years and 6-monthly thereafter.

Results

Treatment interruption for toxicity was required in 39 patients. Median follow-up was 48 months. Ten patients (2.5%) progressed and 117 patients (29.6%) recurred. The tumor characteristics were equally distributed between the two arms. No statistically significant difference in recurrence free survival (RFS) was detected between the two arms (p=0.43). An advantage in terms of recurrence free rate (RFR) in favor of the maintenance arm was evident only until 18 months after TUR (p=0.03). A trend for a higher benefit from maintenance in primary and multiple tumors was detected.

Conclusions

The risk of tumor recurrence is significantly reduced by one-year maintenance only for 18 months after TUR in comparison with patients receiving a 6-week cycle of early intravesical chemotherapy. The disadvantages of prolonged intravesical chemotherapy should be taken into account.

Modified corporoplasty for ventral penile curvature: description of the technique and initial results

PURPOSE

We report our initial results with an original modification of Yachia corporoplasty to correct congenital and acquired ventral penile deviations.

MATERIALS AND METHODS

A total of 12 patients with congenital or acquired ventral curvature of the penis underwent modified corporoplasty. The surgical procedure, which was performed during artificial erection, consists of Yachia plasty done in the bed of the deep dorsal vein, which was previously resected. To our knowledge the procedure that we describe is the only corporoplasty for ventral deviation that does not require any manipulation of the neurovascular bundle but ensures at the same time definitive coalescence of the tunical edges.

RESULTS

Penile curvature was completely eliminated in all patients. No change in erectile function was reported by 11 patients (92%). Eight patients (67%) reported penile shortening (1 to 2.5 cm) but the decreased length did not cause interference with sexual activity. No other surgery related complication, such as pain or loss of sensitivity, was reported. Ten of the 12 patients interviewed (83%) reported full satisfaction with the results. Two patients (17%) reported partial satisfaction.

CONCLUSIONS

The modified Nesbit procedure that we propose allows complete and definitive correction of ventral penile curvature without any manipulation of the dorsal bundle. Excellent penile straightening and the lack of significant postoperative complications result in high patient satisfaction rates.

Detrusor pressure uroflowmetry studies in women: effect of 4 Fr transurethral

PURPOSE

Pressure flow technique on males is considered a standard diagnostic procedure to investigate the voiding process, while on female this is still under investigation. Many studies have been conducted in order to establish a female bladder outlet obstruction nomograms using a 7 Fr catheter, but recently a report showed that 7 Fr catheter may adversely affect the voiding process on women. We studied the effect of 4 Fr urethral catheter in women undergoing pressure flow evaluation in order to assess any detrimental effect in the voiding process.

MATERIALS

We evaluated a database of 85 patients referred for lower urinary tract symptoms. First, all patients had free uroflowmetry and then underwent pressure flow studies utilizing two catheters: a 12 Fr for filling and a 4 Fr mono J for measuring detrusor pressure. After filling we removed the 12 Fr catheter and pressure flow was performed leaving the 4 Fr only in the urethra. As positive correlation of flow rate with voided volume is well established, we selected only 33 patients who had similar prevoided volumes varying by less than 30% and free and intubated flow parameters were compared according to volume categories in order to strengthen the statistic analysis.

RESULTS

In each group all the free and pressure flow parameters were not statistically different. Only in the group who voided within 250 and 500 ml we found the pressure flow voiding time to be almost longer than the free flow equivalent, but not statistically different (31.1 +/- 15 versus 56.7 +/- 49.3; p = 0.05). Furthermore we did not find any difference in free and intubated morphology of curves.

CONCLUSIONS

A 4 Fr transurethral catheter does not affect adversely the voiding process in women undergoing pressure flow studies for lower urinary tract symptoms. This finding has very important clinical implications for interpreting female voiding patterns and may be considered the best tool to define bladder outlet obstruction on women.