Day Care Neurosurgery: Skill and Technical Advancement

IF 0.3 Q4 SURGERY Indian Journal of Neurosurgery Pub Date : 2022-08-01 DOI:10.1055/s-0042-1757119
A. Jagetia
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Abstract

DOI https://doi.org/ 10.1055/s-0042-1757119 ISSN 2277-954X Lower back problems are increasing worldwide due to changing lifestyle, prolonged use of digital technology, and increased use of diagnostic modalities such as Xrays, computed tomography (CT) scan, and magnetic resonance imaging. Increased diagnostic yield has led to increase in spine surgery. The conventional surgery for spine diseases are gradually shifting to minimal invasive spine surgery (MISS) using endoscope or microscope considering its advantages over surgery with big incision and massive muscle dissection. The biggest advantage is same day discharge unlike many neurosurgical procedures. This helps in cutting the cost of treatment to a major extent, less infection, resuming the work early, and above all, a person can go home same day, as “Home is oasis.” The microscopic surgery for disc can be done even with the same length of incision as the MISS; however, the muscle dissection and detachment from spinous process in microscopic surgery with conventional retraction of muscle make it a maximal invasive surgery. MISS needs basic understanding of spine anatomy. As the MISS is emerging as superior surgical procedure for majority spinal pathologies, young neurosurgeon would not have much exposure of detailed spinal anatomy as many anatomical structures in MISS use tactile sensations to localize unlike maximal invasive surgery where visual perception dominates. This would require cadaveric dissections, simulators or anatomy can be understood by cases subjected to open maximal invasive dissections not suitable for minimal exposure. However, use of intraoperative Carms, navigation with ultrasound, CT scan, and/or robots will be the future to understand the bony details of spine. Navigation and robotic has increased the accuracy of spinal instrumentation and success rate of MISS. After reading and analyzing the articles by Kumar et al and Dubey and Agrawal,1,2 it seems the skills and advancement in spinal surgery has made day care surgery possible especially for disc surgery. The other day care procedures for spine are ozone nucleolysis, nucleoplasty, etc.3 For complete extruded disc where disc acts as extradural mass, it might be difficult to identify the relation of root with the disc in MISS which can be overcome to some extent by transforaminal disc injection of methylene blue with iodine containing dye (omnipaque) into the disc before giving incision. This makes disc blue and easily distinguishable. Kumar et al described basics of MISS using tubular retractor, nuances, and technique for beginners.1 Dubey and Agrawal2 used posterolateral transforaminal approach for tumor removal, and ultrasound has been used to localize the foramen along with C-arm. Use of tracked ultrasound technology in spine if substantially recognized, the radiation dose can be reduced to all working in the operation room. Use of standalone ultrasound should be cautiously done in spine localization, however, it is commonly used by anesthetists to give nerve blocks and lumbar punctures.4 Doppler can also be a useful tool to localize vertebral artery in these situations. Authors described the unique reverse lateral mass fixation which can provide better bone purchase. This second issue of the year should add on to the existing knowledge of the readers and the credit goes to the hard work of authors and the critical, time-consuming efforts of the reviewers.
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日托神经外科:技能和技术进步
由于生活方式的改变、数字技术的长期使用以及x射线、计算机断层扫描(CT)扫描和磁共振成像等诊断方式的使用增加,腰背部问题在全球范围内正在增加。诊断率的提高导致脊柱手术的增加。由于内窥镜或显微镜微创手术相对于大切口和大量肌肉剥离手术的优势,传统的脊柱疾病手术正逐渐转向微创脊柱手术。与许多神经外科手术不同,最大的优点是当天出院。这有助于在很大程度上降低治疗费用,减少感染,尽早恢复工作,最重要的是,一个人可以在当天回家,因为“家是绿洲”。椎间盘显微手术即使切口长度与MISS相同,也可以完成;然而,在常规的显微手术中,肌肉的剥离和棘突的脱离使其成为一种最大的侵入性手术。MISS需要对脊柱解剖有基本的了解。由于MISS正在成为大多数脊柱疾病的优越外科手术,年轻的神经外科医生不会有太多的详细的脊柱解剖,因为MISS的许多解剖结构使用触觉来定位,而不像最大侵入性手术,视觉感知占主导地位。这将需要尸体解剖,模拟器或解剖可以理解的情况下,受到开放的最大侵入性解剖不适合最小暴露。然而,术中使用Carms、超声导航、CT扫描和/或机器人将是了解脊柱骨骼细节的未来。导航和机器人提高了脊柱内固定的准确性和miss的成功率。在阅读和分析Kumar等人以及Dubey和Agrawal 1,2的文章后,似乎脊柱外科的技能和进步使日间护理手术成为可能,尤其是椎间盘手术。脊柱的其他日间护理程序是臭氧核溶解,核成形术等。3对于椎间盘作为硬膜外肿块的完全膨出的椎间盘,在MISS中可能难以识别根与椎间盘的关系,在切开前通过椎间孔椎间盘注射含碘染料亚甲基蓝(omnipaque)在一定程度上可以克服这一问题。这使得圆盘呈蓝色,很容易区分。Kumar等人描述了使用管状牵开器的MISS的基础知识、细微差别和初学者的技术Dubey和Agrawal2采用后外侧经椎间孔入路切除肿瘤,超声定位椎间孔及c臂。如果在脊柱中使用跟踪超声技术得到实质性认可,则可将辐射剂量降低到所有在手术室工作的人员。在脊柱定位时应谨慎使用独立超声,然而,麻醉师通常使用它来进行神经阻滞和腰椎穿刺在这些情况下,多普勒也可以是定位椎动脉的有用工具。作者描述了独特的反向侧块固定,可以提供更好的骨购买。今年的第二期应该是对读者现有知识的补充,这要归功于作者的辛勤工作和审稿人的关键、耗时的努力。
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CiteScore
0.40
自引率
0.00%
发文量
52
审稿时长
12 weeks
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