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This study explores the usefulness of virtual simulation training for learning to place pedicle screws in the lumbar spine.Twenty-six senior medical students anonymously participated and were randomized into two groups (A = no simulation; B = simulation). Both groups were given 15 minutes to place two pedicle screws in a sawbones model. Students in Group A underwent traditional visual/verbal instruction whereas students in Group B underwent training on pedicle screw placement in the ImmersiveTouch simulator. The students in both groups then placed two pedicle screws each in a lumbar sawbones models that underwent triplanar thin slice computerized tomography and subsequent analysis based on coronal entry point, axial and sagittal deviations, length error, and pedicle breach. The average number of errors per screw was calculated for each group. Semi-parametric regression analysis for clustered data was used with generalized estimating equations accommodating a negative binomial distribution to determine any statistical difference of significance.A total of 52 pedicle screws were analyzed. The reduction in the average number of errors per screw after a single session of simulation training was 53.7% (P = 0.0067). The average number of errors per screw in the simulation group was 0.96 versus 2.08 in the non-simulation group. The simulation group outperformed the non-simulation group in all variables measured. The three most benefited measured variables were length error (86.7%), coronal error (71.4%), and pedicle breach (66.7%).Computer-based simulation appears to be a valuable teaching tool for non-experts in a highly technical procedural task such as pedicle screw placement that involves sequential learning, depth perception, and understanding triplanar anatomy.

Background: Shifting paradigms in neurosurgical education are promoting the development of different simulators in order to promote faster and safer surgical training. Neuroendoscopy simulators have been created with the intention of decreasing the learning curve of resident training in neuroendoscopy techniques. The objective was to study the potential usefulness of organized implementation of neuroendoscopy simulators in resident training, with particular attention to resident feedback and cost. Methods: A total of 19 residents from two separate academic institutions performed 83 simulated endoscopic procedures. These were classified as ventricular (n = 49) and skull base (n = 34). In turn, each procedure was classified into one of three difficulty levels (easy, medium, and hard). Evaluations regarding self-perceived performance were completed after each exercise in accordance with a Physician Performance Diagnostic Inventory Scale based on the Likert format. Subject identification was blinded to junior or senior resident. Wilcoxon rank testing was used to compare the self-perceived performance improvement within and between both groups. Results: Perceived improvement was statistically significant for all the ventricular and skull base/pituitary simulation procedures listed (P5 0.001) based on the Wilcoxon sign rank test. These results were not particularly influenced by simulation exercise group (ventricular vs skull base, P = 0.48), institution (United States vs Brazil, P = 0.44), resident training level (junior vs senior, P = 0.48), or the level of difficulty of the simulation procedure (easy, medium, hard, P = 0.98). The average cost of the ventricular and skull base/pituitary simulation modules was US$6367.50 and US$7065.50, respectively, per program. Conclusion: The use of neuroendoscopic surgery simulators in neurosurgical training is regarded favorably by trainees and should be considered as an adjuvant in neurosurgical simulation training curricula.

Objective To understand the perceived utility of a novel simulator to improve operative skill, eye-hand coordination, and depth perception. Methods We used the ImmersiveTouch simulation platform (ImmersiveTouch, Inc., Chicago, Illinois, USA) in two U.S. Accreditation Council for Graduate Medical Education−accredited neurosurgical training programs: the University of Chicago and the University of Texas Medical Branch. A total of 54 trainees participated in the study, which consisted of 14 residents (group A), 20 senior medical students who were neurosurgery candidates (group B), and 20 junior medical students (group C). The participants performed a simulation task that established bipolar hemostasis in a virtual brain cavity and provided qualitative feedback regarding perceived benefits in eye-hand coordination, depth perception, and potential to assist in improving operating skills. Results The perceived ability of the simulator to positively influence skills judged by the three groups: group A, residents; group B, senior medical students; and group C, junior medical students was, respectively, 86%, 100%, and 100% for eye-hand coordination; 86%, 100%, and 95% for depth perception; and 79%, 100%, and 100% for surgical skills in the operating room. From all groups, 96.2% found the simulation somewhat or very useful to improve eye-hand coordination, and 94% considered it beneficial to improve depth perception and operating room skills. Conclusion This simulation module may be suitable for resident training, as well as for the development of career interest and skill acquisition; however, validation for this type of simulation needs to be further developed.

Manual skill is important for surgeons, but current methods to evaluate sensory-motor skills in applicants to a surgical residency are limited.To develop a method of testing sensory-motor skill using objective and reproducible virtual reality simulation.We designed a set of tests on a 3-dimensional surgical simulator with head and arm tracking, colocalization, and haptic feedback: (1) "trajectory planning in a simulated vertebra," ie, 3-dimensional memory and orientation; "hemostasis in the brain," ie, motor planning, sequence, timing, and precision; and "choose the softest object," ie, haptic perception. We also derived a weighted combined score for all tasks.Of the 55 consecutive applicants to a neurosurgery residency approached, 46 performed at least 1 task, and 36 performed all tasks. For the trajectory planning task, the distance from target ranged from 3 to 30 mm, with 25 of 36 in the 6- to 18-mm range. In the motor planning test, the duration between cauterization attempts ranged between 5 and 22.5 seconds, peaking at 10 to 12.5 seconds in 15 of 36 participants. In the haptic perception test, linear regression demonstrated increased variability in performance with increasing difficulty of task (R = 0.6281). In all tests, performance followed a roughly bell-shaped curve. The combined weighted score of all tests demonstrated a better bell curve distribution, with scores ranging from 0.275 to 0.71 (mean, 0.47; median, 0.4775; SD, 0.1174).Our study represents a first step in the direction of an objective, standard, computer-scored test of motor and haptic ability.

BACKGROUND:The effort required to introduce simulation in neurosurgery academic programs and the benefits perceived by residents have not been systematically assessed.OBJECTIVE:To create a neurosurgery simulation curriculum encompassing basic and advanced skills, cadaveric dissection, cranial and sp

Object The object of this study was to describe the utility and safety of using a single probe for combined intraoperative navigation and subcortical mapping in an intraoperative MR (iMR) imaging environment during brain tumor resection. Methods The authors retrospectively reviewed those patients who underwent resection in the iMR imaging environment, as well as functional electrophysiological monitoring with continuous motor evoked potential (MEP) and direct subcortical mapping combined with diffusion tensor imaging tractography. Results As a navigational tool the monopolar probe used was safe and accurate. Positive subcortical fiber MEPs were obtained in 10 (83%) of the 12 cases. In 10 patients in whom subcortical MEPs were recorded, the mean stimulus intensity was 10.4 ± 5.2 mA and the mean distance from the probe tip to the corticospinal tract (CST) was 7.4 ± 4.5 mm. There was a trend toward worsening neurological deficits if the distance to the CST was short, and a small minimum stimulation threshold was recorded indicating close proximity of the CST to the resection margins. Gross-total resection (95%–100% tumor removal) was achieved in 11 cases (92%), whereas 1 patient (8%) had at least a 90% tumor resection. At the end of 3 months, 2 patients (17%) had persistent neurological deficits. Conclusions The monopolar probe can be safely implemented in an iMR imaging environment both for navigation and stimulation purposes during the resection of intrinsic brain tumors. In this study there was a trend toward worsening neurological deficits if the distance from the probe to the CST was short (< 5 mm) indicating close proximity of the resection cavity to the CST. This technology can be used in the iMR imaging environment as a surgical adjunct to minimize adverse neurological outcomes.

Objective To objectively compare the complexity and diversity of the certification process in Neurological Surgery in European member societies of the World Federation of Neurosurgical Societies. Materials and Methods The attention of this study centers on Europe. We provide here a subgroup analysis based on the responses provided to a 13-item survey. The data received were analyzed and three regional complexity scores (RCS) were designed. To compare national board experience as well as eligibility requirements to access the certification process and obligatory nature of the examinations, a RCS Organizational score was created (RCS-O, 20 points maximum). To analyze the complexity of the examination a RCS Components score was designed (RCS-C, 20 points maximum). The sum of both is presented in a Global RCS score (RCS-G). In addition, a descriptive summary of the certification process per responding society is also provided. Results and Conclusions Based on the data provided by our RCS system, the highest RCS-G was obtained by the United Kingdom (19/40 points) followed by European Association of Neurosurgical Societies, Poland, and Sweden (16/40 points each), Portugal (15/40 points), and Switzerland (14/40 points). The experience from these leading countries should be of value to all countries of the European Union. Peer-Review Article

We report an unusual case of a large metastatic lesion from prostate adenocarcinoma with its epicenter located in Meckel's cave. The patient presented with acute neurological deterioration due to pontomesencephalic, cranial nerve, and temporal lobe compression. This lesion radiologically mimicked a giant trigeminal schwannoma. Complete surgical resection was achieved with improvement in the performance status of the patient. The anatomic relevance the extradural neural axis component in the process of dissemination of prostate adenocarcinoma to the skull base is highlighted.

Angioleiomyomas are benign neoplasms most often located in the subcutaneous tissue of middle-aged individuals and usually confined to the subcuticular and deep dermal layers of the lower extremities. An intracranial site for this tumor is exceedingly rare, with very few reports documenting locations in the neuraxis. To the authors' knowledge the present case represents the first reported instance of an infratentorial angioleiomyoma. The authors conducted a review of selected English-language papers published since 1960 describing well-documented cases of intracranial vascular leiomyomas, with detailed information on the clinical presentation, radiology, pathology, and particulars of surgical management in each case.

Objective: We present a rare case of an isolated superior orbital fissure fracture resulting from blunt injury to the face and presenting with selective cranial nerve deficits surgically treated with a neuroendoscopic approach. The anatomy of the superior orbital fissure is detailed, and the peculiarities of the surgical approach described. Method: A review of the existing literature reveals this is the first reported case of a neuronavigation-assisted endoscopic approach used in the extraction of a superior orbital fracture fragment with good outcome. Current guidelines for an endoscopic approach in orbital trauma are reviewed, and pertinent literature is discussed. Conclusion: Neuronavigation-assisted decompression should be considered as an effective means of removing superior orbital fissure fractures.

Summary Objective. Epithelioid glioblastoma is a rare morphologic subtype of glioblastoma that closely mimics metastatic carcinoma or metastatic melanoma histologically. All previous case reports of this unusual glioblastoma variant have been solitary lesions. We report here the first case to our knowledge of multifocal epithelioid glioblastoma mimicking cerebral metastasis. Clinical presentation. A 67-year-old man with a prior history of mycosis fungoides, a common form of cutaneous T-cell lymphoma, presented with memory loss and impaired peripheral vision. Two discrete brain lesions highly suspicious for metastases were identified by magnetic resonance imaging (MRI). Intervention. The patient underwent two separate craniotomies; both lesions were successfully resected in toto with an excellent post-surgical outcome. Conclusion. Epithelioid glioblastoma is one of the rarest morphologic subtypes of glioblastoma. Here we describe the first case to our knowledge of multifocal epithelioid glioblastoma that convincingly mimicked a secondary metastatic process. Multifocal epithelioid glioblastoma should be included in the differential diagnosis of patients who present with multiple discrete brain lesions. An attempt at gross total resection is recommended when anatomically feasible for definitive histopathological diagnosis and to improve progression free survival of patients who present with similarly ambiguous and potentially misleading multiple lesions.

OBJECT Surgical transposition of the ulnar nerve to alleviate entrapment may cause otherwise normal structures to become new sources of nerve compression. Recurrent or persistent neuropathy after anterior transposition is commonly attributable to a new distal compression. The authors sought to clarify the anatomical relationship of the ulnar nerve to the common aponeurosis of the humeral head of the flexor carpi ulnaris (FCU) and flexor digitorum superficialis (FDS) muscles following anterior transposition of the nerve. METHODS The intermuscular septa of the proximal forearm were explored in 26 fresh cadaveric specimens. The fibrous septa and common aponeurotic insertions of the flexor-pronator muscle mass were evaluated in relation to the ulnar nerve, with particular attention to the effect of transposition upon the nerve in this region. RESULTS An intermuscular aponeurosis associated with the FCU and FDS muscles was present in all specimens. Transposition consistently resulted in angulation of the nerve during elbow flexion when this fascial septum was not released. The proximal site at which the nerve began to traverse this fascial structure was found to be an average of 3.9 cm (SD 0.7 cm) from the medial epicondyle. CONCLUSIONS The common aponeurosis encountered between the FDS and FCU muscles represents a potential site of posttransposition entrapment, which may account for a subset of failed anterior transpositions. Exploration of this region with release of this structure is recommended to provide an unconstrained distal course for a transposed ulnar nerve.

To determine if a computer-based simulation with haptic technology can help surgical trainees improve tactile discrimination using surgical instruments.Twenty junior medical students participated in the study and were randomized into two groups. Subjects in Group A participated in virtual simulation training using the ImmersiveTouch simulator (ImmersiveTouch, Inc., Chicago, IL, USA) that required differentiating the firmness of virtual spheres using tactile and kinesthetic sensation via haptic technology. Subjects in Group B did not undergo any training. With their visual fields obscured, subjects in both groups were then evaluated on their ability to use the suction and bipolar instruments to find six elastothane objects with areas ranging from 1.5 to 3.5 cm2 embedded in a urethane foam brain cavity model while relying on tactile and kinesthetic sensation only.A total of 73.3% of the subjects in Group A (simulation training) were able to find the brain cavity objects in comparison to 53.3% of the subjects in Group B (no training) (P = 0.0183). There was a statistically significant difference in the total number of Group A subjects able to find smaller brain cavity objects (size ≤ 2.5 cm2) compared to that in Group B (72.5 vs. 40%, P = 0.0032). On the other hand, no significant difference in the number of subjects able to detect larger objects (size ≧ 3 cm2) was found between Groups A and B (75 vs. 80%, P = 0.7747).Virtual computer-based simulators with integrated haptic technology may improve tactile discrimination required for microsurgical technique.

Multiple challenges are faced by educators and trainees. These challenges are multidimensional and pertain to a scenario in which trainees have to become in a short period of time competent technical neurosurgeons, while at the same time conscious of economic and professional factors that will influence their practice. It is the duty of societies and leading educators to come together in developing continental methods of training aimed towards “organised learning”. The goal should strictly be the education of our residents, not just the utilisation of their manpower for a number of years.

STUDY DESIGN A case report with systematic review of the literature. OBJECTIVE To report a case of post-traumatic C4-C5 spondyloptosis without neurological deficit not associated with posterior element fractures and presenting in a delayed fashion with fusion in situ of C4 and C5 vertebral bodies influencing the management strategy. SUMMARY OF BACKGROUND DATA Traumatic spondyloptosis of the subaxial cervical spine is typically associated with neurological injury. To the best of the author's knowledge, this is the first case of spondyloptosis not associated with fractures of the posterior elements but with locked facets at C4-C5 and fusion in situ, presenting in a delayed fashion with remarkable paucity of symptoms that was managed surgically. METHODS A 45-year-old male presented 8 months after a motor vehicle collision with radicular arm pain and mild spasticity involving the legs. Cervical radiograph, computed tomographic scan, and magnetic resonance image revealed bilateral locked facets at C4-C5 with spondyloptosis. Fusion had occurred in situ. RESULTS Traction did not correct alignment and the patient underwent circumferential reduction and fusion and postoperative halo-vest placement. At 6-month follow-up, the patient remained neurologically intact with regression of preoperative symptoms. CONCLUSION Longstanding post-traumatic spondyloptosis may lead to fusion in situ complicating the surgical management. Insufficient suspicion during workup can lead to the omission of this important diagnosis, further complicating operative intervention. Traction is not useful when in situ fusion has occurred in delayed presentation cases. LEVEL OF EVIDENCE N/A.

The essential neurosurgery companion / , The essential neurosurgery companion / , کتابخانه دیجیتال جندی شاپور اهواز