Neurosurgical focus最新文献

Objective: Isolated craniosynostosis of the sagittal suture results in scaphocephaly characterized by a long, narrow skull. Surgical correction of this condition remains debated, particularly regarding the necessity of directly addressing frontal bossing. This study aimed to assess the effectiveness of extended strip craniectomy combined with bilateral barrel staving in improving cranial morphology without direct intervention on the forehead.

Methods: This retrospective study included 81 patients diagnosed with isolated sagittal synostosis, treated surgically at an average age of 5.3 months. Three-dimensional photogrammetric scans were obtained 1 day before surgery and 14 days, 3 months, and 12 months postoperatively. The bossing angle, nasofrontal angle, cephalic index, and vertex ratio were analyzed. A control group of age-matched healthy children was used for comparison.

Results: Significant reductions in the bossing angle were observed from preoperatively to 12 months postoperatively, indicating that the intervention contributed to a more normalized cranial shape. The cephalic index increased significantly postoperatively, although it remained lower than that of the control group. The nasofrontal angle remained stable across all time points, with minimal differences between the study and control groups. The vertex ratio decreased significantly over time, suggesting a balanced cranial shape. However, persistent differences between the study and control groups suggest that the intervention did not fully normalize cranial morphology in the short to midterm.

Conclusions: Extended strip craniectomy with bilateral barrel staving, while effective in improving certain aspects of cranial morphology, may not fully equalize cranial shape within the short to midterm. The use of 3D photogrammetry as a noninvasive method for assessing cranial changes is validated in this study and holds promise for broader applications in craniofacial surgery.

Objective: Craniofacial clefts, characterized by congenital disruptions in the development of facial and cranial tissues, often present alongside orbital hypertelorism (ORH), an abnormal increase in the interorbital distance. These conditions pose significant challenges in craniofacial surgery due to the complex anatomical and functional considerations involved. This single-center cohort study retrospectively analyzed 22 patients diagnosed with craniofacial cleft syndromes and ORH who were treated at the Craniofacial Centre, Fatima Plastic and Reconstructive Surgery Hospital between July 2016 and October 2023.

Methods: This study outlines the preoperative evaluations, surgical interventions, and postoperative outcomes of these cases. Surgical techniques varied according to the severity and type of deformity, guided by Tessier's classification system. Procedures included spectacle osteotomy, box osteotomy, and facial bipartition osteotomy, with each approach tailored to address the unique anatomical challenges presented by ORH and associated craniofacial anomalies.

Results: There was a 9% incidence of postoperative infections and a 22.7% incidence of CSF leakage, with a subset of these leading to meningitis. These complications underscore the complexity of managing craniofacial clefts and ORH, highlighting the necessity for meticulous surgical planning and postoperative care.

Conclusions: Despite the challenges, the study demonstrates that individualized, protocol-driven surgical interventions can achieve significant aesthetic and functional improvements in patients with these congenital anomalies.

Objective: The surgical management of craniosynostosis varies without consensus on technique or standard outcomes reporting. The authors of this study aimed to investigate current surgical management of craniosynostosis in the United States.

Methods: Two hundred seventy-five surgeons actively treating craniosynostosis in the United States were surveyed. The results from a 28-item instrument were analyzed according to surgeon specialty, surgeon tenure, and geographic location of practice.

Results: The overall response rate was 47.6% (131/275), and final analyses included 58 plastic and reconstructive surgeons and 69 neurosurgeons from 79 different institutions. The majority of surgeons used internal data registries (65.4%); however, only 17.4% of neurosurgeons and 34.5% of plastic surgeons (p = 0.04) contributed to national or international registries. Neurosurgeons were more likely to offer endoscopic strip craniectomy for unicoronal craniosynostosis (75.4% vs 50.0%, p = 0.05) and unilateral lambdoid craniosynostosis (69.6% vs 48.3%, p = 0.018). Plastic surgeons were more likely to offer spring-assisted cranioplasty for bilambdoid synostosis (20.7% vs 7.2%, p = 0.036) and most other sutures. For all sutures, open cranial vault remodeling remains the most frequently offered technique. Plastic surgeons more often selected the surgical technique based on physical examination (86.2% vs 68.1%, p = 0.02) and recognized a "gold-standard" treatment (51.7% vs 17.4%, p < 0.001). Region did not significantly impact the techniques offered. Compared to surgeons with fewer years of experience, those with 6 or more years of experience were less likely to offer cranial vault remodeling for unilateral lambdoid craniosynostosis (p = 0.002) and those with more than 10 years of experience were less likely to offer cranial vault remodeling for bilateral lambdoid craniosynostosis (p = 0.011).

Conclusions: The authors present the largest description of current craniosynostosis practices in the United States. Reported surgical offerings were overall similar across specialties, regions, and years of surgeon experience. Nearly all surveyed surgeons continue to offer open cranial vault remodeling as an option for all included craniosynostosis variations. Endoscopic strip craniectomy is the second most proposed technique for most sutures, but distraction methods are similarly or more frequently offered in cases of bilateral and multisuture synostoses. Plastic surgeons also report greater spring-assisted repair offers than neurosurgeons, whereas the longest practicing surgeons are less likely to offer open repair in lambdoid cases. Encouraging further contributions to national databases, such as that of the Synostosis Research Group, may provide robust outcome data that can help to identify best practices for managing this complicated pathology.

Objective: Most robots currently used in neurosurgery aid surgeons in placing spinal hardware and guiding electrodes and biopsy probes toward brain targets. These robots are inflexible, cannot turn corners, and exert excessive force when dissecting and retracting brain tissue, limiting their applicability in cranial base surgery. In this study, the authors present a novel soft-pouch robot prototype driven by compressed air and capable of gentle tissue manipulation. The robot is manufactured with technology developed by the authors, with multiple bidirectional bending points and a miniature camera running through the robot's central channel.

Methods: A soft, pneumatically driven pouch manipulator was created using a novel rapid and scalable system (integrated multilayer pouch robots with inkjet-patterned thin films). Made from 4 layers of thin, low-density polyethylene films, the manipulator has a thin deflated profile (152 µm) and contains 5 independent bidirectional joints with 50° range in each direction, as well as a wrapping end-effector. The robot carries a camera through its central channel. Four cadaveric models were used to demonstrate the robotic prototype being maneuvered inside different anatomical structures during simulated endonasal and posterior fossa approaches, with a manually positioned robot base and manually controlled air pressures.

Results: The robot is a pneumatically driven, soft-continuum manipulator with 12 control inputs and 6 independently controllable degrees of freedom. This design enables in-plane obstacle avoidance and orientation control. The robot is trapezoidal-shaped, with a total weight of 0.4 g, a 10-mm-wide distal end, and a length of 138 mm. The variable production cost (materials cost) of the manipulator is approximately $1. The manipulator is maneuvered to enter the maxillary sinus and through the endonasal corridor, demonstrating its potential use for anterior skull base approaches. It is also successfully maneuvered around the pons in a simulated retrosigmoid approach.

Conclusions: This robot offers a promising solution for safely maneuvering through narrow surgical windows encountered during skull base approaches. The multiple bending points of the robot, combined with its passive deformation capacity, allow it to turn around immovable structures, expanding the reach of surgical openings. The cost-effectiveness, rapid production, and scalability of the robot represent additional advantages.

Objective: Despite its potential advantages, robotic surgery has yet to be applied to skull base procedures. Complex anatomy and restricted access have limited the development of robotic skull base surgery. The authors' aim was to conduct a feasibility study of robotic surgery for posterior fossa skull base lesions.

Methods: Six silicone-injected postmortem human heads were prepared for the robotic surgery. Because there was no drilling tool with the robot, specimens were dissected in advance using an endoscope and microscope. The following approaches were investigated: 1) supracerebellar-infratentorial; 2) retromastoid; and 3) posterior occipitocervical junction surgeries. For each approach specific anatomical landmarks were identified, and the surgical freedom (vertical distance angle between the tools) was measured.

Results: In the case of the supracerebellar-infratentorial approach, the authors used 3 burrs with 1.5 cm of diameter: 1 paramedian and 2 laterally. The view of the pineal region was visualized, and sufficient surgical freedom of both tools was secured. The median vertical distance was 1.2 cm (range 1.1-1.8 cm), and the median angle between the tools was 105° (range 92°-110°). On the other hand, in the retromastoid approach, with a single burr 2.5 cm in diameter, the root exit zone of the facial nerve was barely visible, and a space for tools to access was not secured. The median vertical distance was 0.8 cm (range 0.6-1.0 cm), and the median angle between the tools was 10° (range 6°-12°). In the case of the posterior occipitocervical junction approach, the authors used the 3 tubular retractors, 1 in the middle and 2 laterally. Even though the space was narrow, the medulla and adjacent nerves could be identified, and a moderate level of surgical freedom could be obtained for tool mobilization. The median vertical distance was 1.6 cm (range 1.2-2.5 cm), and the median angle between the tools was 90° (range 88°-95°).

Conclusions: Although robotic surgery has yet to be applied to neurosurgery, it is expected to be helpful in posterior fossa skull base surgery if appropriate tools can be developed.

Objective: This study aimed to develop a robotic system with autonomous functionality for holding and manipulating the endoscope in endoscopic endonasal surgery. A cost-effective prototype was created with the goal of using robotic assistance and achieving a more efficient learning curve for endoscopic surgery.

Methods: A Stewart platform-based endoscope holder and positioner robotic system, developed by the Mechatronics Engineering Department of Kocaeli University, was used in conjunction with 3D Slicer and Plus Toolkit open-source health technology software. Following initial configuration on a 3D skull model, the system was applied to a fresh-frozen cadaver.

Results: The robotic system and its registration process proved feasible, allowing the robot to autonomously reach predetermined anatomical points during the nasal step of the surgery. Compared with a previous study by the same authors, the surgery duration was successfully shortened. The experiment yielded positive outcomes in both the artificial skull model and the cadaver. The robotic system effectively performed the nasal stage of the surgery. The integration of a robotic surgical arm in the endoscopic endonasal approach holds the potential to enhance the learning curve through shared experiences. The robot offers assistance to surgeons during the learning phase of the endoscopic endonasal approach, aiding in the identification of anatomical landmarks through preoperative planning.

Conclusions: This system may present advantages such as improved visualization, enhanced maneuverability, and reduced user fatigue compared with conventional methods. These findings show the potential of robotic assistance in endoscopic surgical techniques.

Objective: As robot systems for spine surgery have been developed, they have demonstrated a high degree of accuracy in screw placement without sacrificing safety or surgical efficiency. These robotic systems offer preoperative planning and real-time feedback to enhance surgical precision and mitigate human error. Nevertheless, limitations to their optimal performance remain. The authors analyzed the initial 100 cases of pedicle screw placements performed using the Mazor X robot at their institution, presenting case examples to illustrate the limitations that were experienced, and reviewed current literature on the limitations of robot-assisted spine surgery, emphasizing their impact on accuracy and safety.

Methods: This was a retrospective review of the first 100 cases of robot-assisted pedicle screw placement at the authors' institution between December 2019 and June 2024. All intraoperative CT scans were reviewed for screw accuracy. Malpositioned screws, near misses (screw deviation without injury to the patient), or abandoned robot-assisted attempts were identified, and the underlying reasons were evaluated to determine the limitations of current robot technology.

Results: Of the first 100 cases of robot-assisted pedicle screw placement, there were 20 screw-related complications, of which 14 were near misses, 1 involved neurological injury caused by screw malposition, and 5 were cases in which a robot-assisted attempt was abandoned before manual screw placement. The authors identified the following limitations with current robot technology: registration errors, spine movement after registration, patient body habitus, artifact from metallic implants, poor bone differentiation, skiving, soft-tissue interference, and physical constraints.

Conclusions: Despite the advancements of spine robot systems, several limitations persist, especially in mobile or unstable spine locations and around critical structures. The authors' experience, with provided case examples, further illustrates technical nuances important to understanding and navigating around these limitations. The need for standardized reporting metrics to evaluate and classify emerging technologies is highlighted, emphasizing ongoing technological innovation to enhance the efficacy of robot-assisted spine surgery.

Objective: Microvascular decompression (MVD) in trigeminal neuralgia (TN) is currently managed using an operating microscope (OM). Recent experiences with endoscopy-assisted, fully endoscopic, and exoscopic surgery have been described, aiming to improve ergonomics and image quality. The aim of this study was to report the first series of patients operated on with the aid of a robotic binocular exoscope using a head-mounted display (RoboticScope).

Methods: From September 2023 to March 2024, 9 patients with TN were treated using the RoboticScope. A classic mini-retrosigmoid approach was performed and standard microsurgical techniques were applied. Surgical timing, ergonomics, visual performances, adverse events, and 1-month postoperative pain outcomes were evaluated.

Results: All surgeries were completed without shifting to the OM. Surgeon comfort with the RoboticScope was better compared with the OM and visualization was good. No intraoperative adverse events were recorded. The duration of the procedure was significantly shorter with the RoboticScope compared to those using the OM (median 18 vs 34 minutes, p = 0.0001).

Conclusions: MVD can be safely and effectively performed using the RoboticScope. Surgeons benefit from better ergonomics, stereoscopic image quality, and shorter surgical duration.

Objective: Over the past 3 decades, robotic technology has advanced significantly across surgical fields, driven by improvements in versatility, stability, skill, and tactile properties. Neurosurgery has led the way in integrating robotics to improve the accuracy and safety of procedures that require high precision. This study aimed to present one of the largest series in the literature and investigate the feasibility and effectiveness of robotic assistance in neuro-oncological surgery.

Methods: The authors performed a retrospective review of the medical records of patients who underwent stereotactic biopsy only and biopsy and laser interstitial thermal therapy (LITT) using the Robotic Surgical Assistant (ROSA) system. The ROSA system was used for trajectory planning as well as the precise alignment and insertion of the needle and/or laser catheter. All procedures were performed by a single neurosurgeon. Electronic medical records were reviewed for patient demographics, preoperative clinical deficits, diagnosis, preoperative and postoperative MR images, lesion characteristics including location and volume, postoperative complications, and deficits.

Results: A total of 348 patients were identified. The mean age at surgery was 61.4 years, with 171 (49.1%) females. The most common presentations were GBM (40.5%, n = 141), metastasis (16.4%, n = 57), and radiation necrosis (9.8%, n = 34). A total of 189 (54%) patients underwent stereotactic biopsy only, and 159 (46%) underwent biopsy and LITT. The diagnostic yield of the cases was 98.6%, with only 5 cases having inconclusive pathology. Two (0.6%) patients experienced postoperative complications that resolved during follow-up. Ten (2.9%) patients developed asymptomatic subcentimeter hematomas following the procedure that did not require further intervention. No long-term consequences or permanent deficits occurred in any case within a median follow-up duration of 4.4 months (IQR 1-11.2 months).

Conclusions: These results indicate that a robot-assisted approach for stereotactic biopsies and LITT is associated with a comparable diagnostic yield and safety profile for frameless and frame-based techniques. Its precision, user-friendly interface, and adaptability contribute to its suitability for such procedures. Future research, especially in long-term results and cost-effectiveness, will be crucial in fully understanding the utility and potential of this technology for broader applications in the field.