A novel simulation model for minimally invasive spine surgery.

OBJECTIVE: Minimally invasive spine surgery (MISS) is among the fastest growing technologies in general neurosurgical practice. In addition, great demand exists to teach these skills to neurosurgery residents. With newly enforced work hour restrictions, opportunities to acquire these skills are limited, necessitating development of alternative strategies of education. We describe a novel simulation model for MISS supplemented by resident self-assessment analysis and evaluation. METHODS: The simulator was constructed using a nontransparent Plexiglas frame supplemented with a modified halo frame on which to affix spine specimens. Interchangeable copper tubing was affixed to a 360-degree pivot system to replicate a working portal. Deer skulls and spines were then collected and prepared accordingly. Laboratory exercises were based on the resident's level of training with emphasis on proper drilling techniques. Eight neurosurgery residents were asked to complete the exercises and complete a self-assessment survey regarding their competence level on a scale of 0 to 5, both before and after completing the skill sets. Additionally, they were asked to complete an exit survey that was used to assess the simulation exercises. RESULTS: All exercises were completed successfully with the exception of placing 2 separate pedicle screws through the same portal, which posed difficulty on some specimens because of the of lack of lordosis of the specimens, leading to unfavorable trajectories using a free-hand technique. With regard to the resident self-assessment analysis, the mean confidence rating for performing an MISS laminectomy improved by a difference of 1.25 points (n = 8; 95% confidence interval, 0.66-1.84; P = 0.0015), from 2.50 to 3.75 before and after simulation exercises, respectively, and reached statistical significance. For the senior-level residents, the mean confidence rating for performing MISS placement of pedicle screws using a free-hand technique improved by a difference of 1.00 (n = 3; 95% confidence interval, -1.48-3.48; P = 0.225), from 3.33 to 4.33 before and after simulation exercises, respectively. Results of the exit survey were encouraging. CONCLUSION: The MISS simulator is a feasible, inexpensive, and reproducible adjunct to neurosurgery resident training and provides a new teaching method for spine surgery. Further investigation of this technology is warranted, although multicenter, randomized, controlled trials assessing its validity may not be practical because of ethical constraints with regard to patient safety.

Percutaneous placement of an external drain of the cisterna magna using interventional magnetic resonance imaging in a patient with a persistent cerebrospinal fluid fistula: technical case report.

OBJECTIVE: Cerebrospinal fluid diversion from the cisterna magna has been described previously but has largely been abandoned because of high complication rates and anatomic constraints. Situations still remain in which this may be the best or only alternative. We describe the use of interventional magnetic resonance imaging (iMRI) for the application of this largely forgotten procedure. PRESENTATION: A 28-year-old woman with a previously diagnosed malignant peripheral nerve sheath tumor of the thoracic spine presented with a refractory postoperative cerebrospinal fluid leak complicated by diffuse meningeal carcinomatosis. External lumbar drainage was unsuccessful because of complete tumor obliteration. An attempt at primary closure augmented with muscle flaps was also ineffective. Ventricular drainage was deferred because of concern for tumor seeding, thus necessitating a more aggressive approach. TECHNIQUE: The patient was intubated and placed in the open iMRI portal in a lateral decubitus position. Under direct image guidance, a closed-tip lumbar catheter was inserted into the cisterna magna through an iMRI-compatible biopsy needle and then connected for external drainage. CONCLUSION: To our knowledge, this is the first described use of iMRI technology for catheterization of the cisterna magna for cerebrospinal fluid diversion. Moreover, iMRI technology should be considered in future applications of complex posterior fossa shunting procedures.

Enzymatic synthesis of aminoglycoside antibiotics: novel adenosylmethionine:2-deoxystreptamine N-methyltransferase activities in hygromycin B- and spectinomycin-producing Streptomyces spp. and uses of the methylated products.

Aminocyclitols structurally related to streptamine, a 1,3-diaminocyclitol, are common components of the RNA-binding aminoglycoside antibiotics. The respective aminocyclitol cores of hygromycin B and spectinomycin are N(3)-methyl-2-deoxy-D-streptamine and N(1),N(3)-dimethyl-2-epi-streptamine. Adenosyl[methyl-(14)C]methionine:2-deoxystreptamine N-methyltransferase activities were detected in extracts of early-stationary-phase mycelia of the hygromycin B producer Streptomyces hygroscopicus subsp. hygroscopicus ATCC 27438 and the spectinomycin producer Streptomyces flavopersicus ATCC 19756. Extracts of both strains methylated the N(1)- and N(3)-amino groups of 2-deoxystreptamine, streptamine, and 2-epi-streptamine; the N(1)-amino group of N(3)-methyl-2-deoxy-D-streptamine, and the N(3)-amino group of N(1)-ethyl-2-deoxy-D-streptamine, the semisynthetic aminocyclitol of netilmicin. The mono[(14)C]methyl derivatives of 2-deoxystreptamine, streptamine, and 2-epi-streptamine were excellent substrates for L-glutamine:aminocyclitol aminotransferase and thereby provided a sensitive assay for derepression of this key enzyme, a generic biosynthetic marker that we have shown to be the only enzyme common to the biosyntheses of all major aminoglycoside antibiotics. Other prospective uses for these methyl-labeled 2-deoxystreptamine analogs are also described.