Purpose: To evaluate the learning curve for exoscope and three-dimensional (3D) 4K hybrid visualization in terms of operating time, advantages, disadvantages, and surgical complications in tubular-access minimally invasive spine surgery (MISS) and to assess surgeon satisfaction with image quality, ergonomics, and ability to perform target site treatment.
Overview of Literature: Working through tubular retractors poses a challenge. The extreme angulations during microsurgical decompression, especially contralateral decompression, require surgeons to work non-ergonomically. An exoscope allows surgeons to work ergonomically and independently of the microscope oculars as visualizations are now provided by large 3D 4K monitors. However, the value and efficacy of solely depending on an exoscope and 3D 4K monitors during microsurgical work are still unknown.
Methods: Seventy-four patients (99 levels) underwent trans-tubular MISS between March 2018 and January 2019. Five patients were excluded: one had pyogenic discitis, two had revisions, and two were trans-tubular transoral. In total, we analyzed 69 for operating time, blood loss, and complications. The learning curve graph was plotted using the surgical time for each procedure. Surgeons were asked to rate their satisfaction with image quality, ability to maintain ergonomic posture, and efficient target site treatment.
Results: For tubular microdiscectomy, the operating time plateaued after six cases, and for tubular decompression and minimally invasive transforaminal lumbar interbody fusion, the operating time plateaued after nine cases. Mean operating time was significantly reduced after the plateau. Complications included four cases of dural tear. All patients improved symptomatically, and there were no postoperative neurological deficits.
Conclusions: Use of the exoscope has a short learning curve. Surgeons benefit from improved ergonomic posture during surgery, and resident teaching appears to be good. The only drawback is the need to rearrange the operating table setup. Complications were comparable to those when using the surgical microscope. An exoscope with hybrid digital visualization provides excellent visualization, depth perception, clarity, and precision target site treatment.
Purpose: To evaluate the effect of interbody distraction by OLIF for the treatment of adult spinal deformity.
Overview of Literature: Adult spinal deformity with symptomatic stenosis has been addressed conventionally using a direct posterior decompression approach with fusion. However, stenotic symptoms can also be alleviated indirectly through restoration of intervertebral and foraminal heights and correction of spinal alignment.
Methods: Twenty-eight patients with adult spinal deformity underwent OLIF combined with modified cortical bone trajectory screws at 94 lumbar levels with neuromonitoring. The patients were divided into three groups based on their preoperative lumbar lordosis: group A, <0°; group B, 0°-20°; and group C, >20°. The cross-sectional area (CSA) of the thecal sac was measured preoperatively and postoperatively on axial magnetic resonance images. Differences in CSA were evaluated, and the relationship between the CSA extension ratio and preoperative CSA was assessed. Changes in disc height and segmental disc angle were measured from plain radiographs.
Results: OLIFs were performed successfully without neural complications. In group A, the mean CSA increased from 120.6 mm2 preoperatively to 148.5 mm2 postoperatively (p <0.001). The mean CSA for group B increased from 120.1 mm2 preoperatively to 154.4 mm2 postoperatively (p <0.001). Group C had an increase in mean CSA from 114.7 mm2 preoperatively to 160.7 mm2 postoperatively (p <0.001). The mean CSA enlargement ratio was 27.5%, 32.1%, and 60.4% in groups A, B, and C, respectively. The mean CSA extension ratio was inversely correlated with preoperative CSA.
Conclusions: The effect of indirect neural decompression in adult spinal deformity with OLIF varies with the degree of preoperative lumbar lordosis.
Methods: All patients admitted into our centre were screened for eligibility and those who underwent surgery from September 2016 to September 2017 had a D-dimer screening after surgery, followed by an ultrasound Doppler if the former was positive. The choice of anticoagulant therapy was not influenced by this study, and observation of the use was in keeping with usual practices in our centre was done.
Results: A total number of 331 patients were recruited in this study, however, after the inclusion and exclusion criteria had been met, 320 patients remained eligible, i.e. suitable for analysis. The mean age of our patients was 46 years, with 66% being male patients. A majority of the cases in this study were cranial related, with only 5% being spine surgeries. On the multivariate analysis, the Well's score and the number of days in bed remained statistically significant, after adjusting for age group, gender, ethnicity, type of central venous access and type of DVT prophylaxis with an adjusted odd's ratio, and a confidence interval of 95%, and P < 0.05 for each.
Conclusion: Well's scoring and number of days in bed were independent factors affecting the rate of DVT in patients undergoing neurosurgical procedures in our centre.
MATERIAL AND METHODS: This is a retrospective study of epilepsy cases with VEM performed in University Malaya Medical Center (UMMC), Kuala Lumpur, from January 2012 till August 2016.
RESULTS: A total of 137 cases were included. The mean age was 34.5 years old (range 15-62) and 76 (55.8 %) were male. On the first 24 -h of recording (D1), 81 cases (59.1 %) had seizure occurrence, and 109 (79.6 %) by day 2 (D2). One-hundred and nine VEMs (79.6 %) were diagnostic, in guiding surgical decision or further investigations. Of these, 21 had less than 2 seizures recorded in the first 48 h but were considered as diagnostic because of concordant interictal ± ictal activities, or a diagnosis such as psychogenic non-epileptic seizure was made. Twenty-eight patients had extension of VEM for another 24-48 h, and 11 developed seizures during the extension period. Extra-temporal lobe epilepsy and seizure frequency were significant predictors for diagnostic 48 -h VEM. Three patients developed complications, including status epilepticus required anaesthetic agents (1), seizure clusters (2) with postictal psychosis or dysphasia, and all recovered subsequently.
CONCLUSIONS: 48-h video EEG monitoring is cost-effective in resource limited setting.
METHODS: We conducted an online survey among neurosurgery residents in Indonesia, Malaysia, Philippines, Singapore, and Thailand from May 22 to 31, 2020 using Google Forms. The 33-item questionnaire collected data on elective and emergency neurosurgical operations, ongoing learning activities, and health worker safety.
RESULTS: A total of 298 of 470 neurosurgery residents completed the survey, equivalent to a 63% response rate. The decrease in elective neurosurgical operations in Indonesia and in the Philippines (median, 100% for both) was significantly greater compared with other countries (P < 0.001). For emergency operations, trainees in Indonesia and Malaysia had a significantly greater reduction in their caseload (median, 80% and 70%, respectively) compared with trainees in Singapore and Thailand (median, 20% and 50%, respectively; P < 0.001). Neurosurgery residents were most concerned about the decrease in their hands-on surgical experience, uncertainty in their career advancement, and occupational safety in the workplace. Most of the residents (n = 221, 74%) believed that the COVID-19 crisis will have a negative impact on their neurosurgical training overall.
CONCLUSIONS: An effective national strategy to control COVID-19 is crucial to sustain neurosurgical training and to provide essential neurosurgical services. Training programs in Southeast Asia should consider developing online learning modules and setting up simulation laboratories to allow trainees to systematically acquire knowledge and develop practical skills during these challenging times.
METHODS: Miri General Hospital is a remote center in Sarawak, Malaysia, serving a population with difficult access to neurosurgical services. Two neurosurgeons were stationed here on a rotational basis every fortnight during the pandemic to handle neurosurgical cases. Patients were triaged depending on their urgent needs for surgery or transfer to a neurosurgical center and managed accordingly. All patients were screened for potential risk of contracting COVID-19 prior to the surgery. Based on this, the level of personal protective equipment required for the health care workers involved was determined.
RESULTS: During the initial 6 weeks of the Movement Control Order in Malaysia, there were 50 urgent neurosurgical consultations. Twenty patients (40%) required emergency surgery or intervention. There were 9 vascular (45%), 5 trauma (25%), 4 tumor (20%), and 2 hydrocephalus cases (10%). Eighteen patients were operated at Miri General Hospital, among whom 17 (94.4%) survived. Ninety percent of anticipated transfers were avoided. None of the medical staff acquired COVID-19.
CONCLUSIONS: This framework allowed timely intervention for neurosurgical emergencies (within a safe limit), minimized transfer, and enabled uninterrupted neurosurgical services at a remote center with difficult access to neurosurgical care during a pandemic.
CASE PRESENTATION: We described a 43 years old male who presented with a right mastoid swelling, nine years after a right retro-sigmoid craniotomy and excision for a cerebellopontine angle meningioma. He also had multiple cranial neuropathies involving trigeminal, facial and vestibulocochlear nerves. Temporal bone CT and MRI showed features suggestive of cholesterol granuloma with extensive bony erosions. He was treated with surgical excision and drainage where bone wax residues were found intraoperatively. Histopathological analysis of the lesion confirmed the diagnosis of cholesterol granuloma. Post-operatively, the mastoid swelling resolved and his recovery was uneventful.
CONCLUSION: Our case showed that CG could manifest as a complication of bone wax usage in a neurosurgical procedure. Even though further study is needed to draw a definitive conclusion on this theory, we believe this paper will contribute to the current literature as it is the only reported case of cholesterol granuloma with bone wax as the possible causative agent. This is important so that surgeons are aware of this potential complication and use this haemostatic agent more judiciously.