Intra-Operative Ultrasound: Tips and Tricks for Making the Most in Neurosurgery
Roberto Altieri, MD, Neurosurgeon, Francesco Zenga, MD, Neurosurgeon, Antonio Melcarne, MD, Neurosurgeon, Giuseppe Di Perna, MD, Resident in Neurosurgery, Chiara Fronda, MD, Neurosurgeon, Fabio Cofano, MD, Resident in Neurosurgery, Alessandro Ducati, MD, Professor of Neurosurgery, Diego Garbossa, MD, PhD, Professor of Neurosurgery, University of Turin, Turin, Italy, Francesco Maria Calamo Specchia, MD, Neurosurgeon, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy, Giuseppe La Rocca, MD, Neurosurgeon, Giovanni Sabatino, MD, Neurosurgeon, Giuseppe Maria Della Pepa, MD, Neurosurgeon, Alessandro Olivi, MD, Professor of Neurosurgery, Institute of Neurosurgery, Catholic University of Rome, Rome, Italy
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Purpose: Advances in intraoperative imaging and neuronavigation techniques have positively affected glioma surgery. The desire to reduce brain-shift-related problems while achieving the real-time identification of lesions and residual and anatomical relationships has strongly supported the introduction of intraoperative ultrasound (ioUS) in neuro-oncological surgery. This paper presents tips based on our experience with ioUS in neurosurgery.
Methods: We retrospectively analyzed 264 patients who underwent high-grade glioma (HGG) resection at the University of Turin and 60 patients who were treated at the University of Rome.
Results: The main issues are the correct choice of the probe and how to evaluate the anatomy to understand how the information from the three common US planes (axial, sagittal and coronal plane) can be used in each case. It is also important to correctly identify anatomical structures in ioUS imaging. In a normal brain, the sulci, sickle, tentorium, choroid plexus, ependyma and the walls of the vessels are all hyperechoic. In addition, some structures are hypoechoic with a homogeneous acoustic gradient: ventricles, cysts and everything that contains liquor. Tumors are usually hyperechoic in ioUS because of their higher cellularity. Conversely, acute edema that contains fluid is hypoechoic, while chronic edema is hyperechoic.
Conclusions: IoUS is a real-time, accurate and inexpensive imaging method. The difficulties of interpretation can be overcome by experience in US imaging and a better understanding of the interaction between navigation and imaging fusion techniques. Training on a large number of cases is important for the correct assessment of ioUS information to obtain valuable, real-time information during HGG surgery.
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Backpack Forces on the Spine
Kenneth K. Hansraj, MD, Chief of Spine Surgery, Jonathan A. Hansraj, Research Associate, Biomechanics, Marcia D. Griffin-Hansraj, DO, Chief of Rehabilitation Medicine, James Kiernan, MS, Research Associate, Biomechanics, Niro Subesan, PA, Research Associate, Biomechanics, Bogdan Firtat, PhD, Researcher in Biomechanics, Alaa Elsisi, PhD, Researcher in Biomechanics, New York Spine Surgery & Rehabilitation Medicine, Hudson Valley, NY
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Object: Backpacks are standard load carriers for people of all ages, especially school children and the military. Previous studies have described the impact of the forces exerted by backpacks on load distribution, back pain, and gait. The objective of this study was to use finite element analysis (FEA) to assess the effects of incremental weights in a backpack on the spine.
Methods: To assess the forces experienced by the spine under the incremental addition of weight to a backpack, we performed a finite element simulation using commercially available 'BodyParts3D/Anatomography' data, which were imported into FEA software. We studied two different scenarios: 1) a regular backpack with incrementally placed weights using both shoulder straps with the spine in a neutral position, and 2) a regular backpack with incrementally placed weights using both shoulder straps with the spine tilted forward 20 degrees. The spine model was physiologically accurate.
Results: For all of the added weights examined (1-100 pounds; 0.45-45.36 kg), the force experienced by the neutral spine was 7.2-fold the added weight. For the 20 degrees-forward posture, this value rose to 11.6-fold. Conclusions: These findings should help to clarify the forces experienced by the spine due to objects in a backpack. For example, this should help spinal surgeons to better understand the tremendous importance of sagittal plane alignment in planning their surgical reconstructions.
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Step-by-step Illustration of the Cranial Bifrontal Approach
Marcelo Galarza, MD, PhD, Associate Professor, Regional Service of Neurosurgery, University Hospital Vírgen de la Arrixaca, Murcia, Spain
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Based on experience with several hundreds of adult and pediatric patients in whom the cranial bifrontal approach was used to achieve different surgical objectives, this paper describes this approach in a step-by-step manner with illustrations. This is a basic approach to the anterior cranial fossa that enables the preservation of most bridging veins. The bifrontal approach, whether basal, interhemispheric, or both, allows a wider bilateral operative field with better orientation and views of important neural structures and perforating arteries, without needing to be combined with other approaches. The following description should be regarded as a basic technique to arrive at a definite location within the anterior cranial compartment and beyond, rather than as rigid steps that must be followed rigorously. These illustrations are intended to present essential principles of a standard bifrontal approach. Since the same principles can be followed for every bifrontal approach, this technique along with the surgical results can be constantly improved.
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Facial Nerve Schwannoma: A Case Report, Radiological Features and Literature Review
Giulia Pilloni, MD, Chief Resident, Barbara Massa Micon, MD, Consultant, Roberto Altieri, MD, Chief Resident, Francesco Zenga, MD, Consultant, Alessandro Ducati, MD, PhD, Full Professor, Diego Garbossa, MD, PhD, Assistant Professor, University of Turin, Turin, Italy, Fulvio Tartara, MD, Consultant, Director of Department of Neurosurgery, Cremona Hospital, Cremona, Italy
Facial nerve schwannoma localized in the middle fossa is a rare lesion. We report a case of a facial nerve schwannoma in a 30-year-old male presenting with facial nerve palsy.
Magnetic resonance imaging (MRI) showed a 3 cm diameter tumor of the right middle fossa. The tumor was removed using a sub-temporal approach. Intraoperative monitoring allowed for identification of the facial nerve, so it was not damaged during the surgical excision. Neurological clinical examination at discharge demonstrated moderate facial nerve improvement (Grade III House-Brackmann).
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3-11-2017
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A Better Method for Repairing Lumbar Dural Tears? A Review of the Literature
Evan Mullen, MS, John Caridi, MD, Assistant Professor of Neurosurgery and Orthopaedics, Jeremy Steinberger, MD, House Staff, Raj Shrivastava, MD, Associate Professor of Neurosurgery and Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, New York
Although dural tears are a frequent complication of lumbar spine surgery, no standardized method exists for their treatment. Given the growing number of spinal procedures performed worldwide, it is important to codify an effective strategy for managing repair of the dura mater. This paper is a review of the comparative effectiveness of the current treatments available for dural tears. Our findings suggest that, where possible, repair should be made via direct suturing using material that minimizes the difference between the size of needle and thread. Adhesives and glues, such as DuraSeal™ (Medtronic, PLC, Minneapolis, Minnesota), should be considered to augment the strength of the repair and collagen xenografts should be used where suturing is impossible. An enhanced effort in this research area is necessary to reinforce and improve these recommendations.
31/914
12-11-2017
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