Videoexoscopic real-time intraoperative navigation for spinal neurosurgery: a novel co-adaptation of two existing technology platforms, technical note.

Image-guided approaches to spinal instrumentation and interbody fusion have been widely popularized in the last decade [1-5]. Navigated pedicle screws are significantly less likely to breach [2, 3, 5, 6]. Navigation otherwise remains a point reference tool because the projection is off-axis to the surgeon's inline loupe or microscope view. The Synaptive robotic brightmatter drive videoexoscope monitor system represents a new paradigm for off-axis high-definition (HD) surgical visualization. It has many advantages over the traditional microscope and loupes, which have already been demonstrated in a cadaveric study [7]. An auxiliary, but powerful capability of this system is projection of a second, modifiable image in a split-screen configuration. We hypothesized that integration of both Medtronic and Synaptive platforms could permit the visualization of reconstructed navigation and surgical field images simultaneously. By utilizing navigated instruments, this configuration has the ability to support live image-guided surgery or real-time navigation (RTN). Medtronic O-arm/Stealth S7 navigation, MetRx, NavLock, and SureTrak spinal systems were implemented on a prone cadaveric specimen with a stream output to the Synaptive Display. Surgical visualization was provided using a Storz Image S1 platform and camera mounted to the Synaptive robotic brightmatter drive. We were able to successfully technically co-adapt both platforms. A minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) and an open pedicle subtraction osteotomy (PSO) were performed using a navigated high-speed drill under RTN. Disc Shaver and Trials under RTN were implemented on the MIS TLIF. The synergy of Synaptive HD videoexoscope robotic drive and Medtronic Stealth platforms allow for live image-guided surgery or real-time navigation (RTN). Off-axis projection also allows upright neutral cervical spine operative ergonomics for the surgeons and improved surgical team visualization and education compared to traditional means. This technique has the potential to augment existing minimally invasive and open approaches, but will require long-term outcome measurements for efficacy.

Clipping or coiling of cerebral aneurysms.

The management of a patient with a cerebral aneurysm is complex, and two accepted treatment modalities are now available. The superiority of either of the treatment options has not been defined, but data are now available with regard to the safety and efficacy of each modality and can be used to decide what is best for individual patients when combined with other important variables, such as the patient's expected longevity, specific aneurysm factors (eg, size, dome-to-neck ratio, location), and operator's experience. This complex decision entertaining all the variables should ensure that patients receive the most appropriate care. New developments in the endovascular management of cerebral aneurysms are likely to alter this algorithm.

Cosmetic concerns in posterior fossa skull base surgery.

Although cosmetic defects produced by posterior fossa surgery may not seem obvious, a poor cosmetic result can overshadow an otherwise successful operation. It is important to approach the operation with knowledge that each phase of a surgical procedure either directly or indirectly influences the eventual cosmetic result. The careful use of anatomic dissection and repair and attempts to reconstitute bony defects to their native contour as well as avoidance of complications all contribute to excellent cosmetic outcomes.