Burnout in Neurosurgery.

BACKGROUND: Burnout is a pervasive psychosocial syndrome that manifests as a chronic response to interpersonal stressors encountered in the occupational setting. Neurosurgeons exhibit a high prevalence rate of burnout, ranging from 33% to 67%. The primary objective of this study is to examine the prevalence of Burnout syndrome within the neurosurgical community and identify the contributing factors. METHODS: A prospective observational study was conducted utilizing an anonymous survey format, incorporating the Maslach Burnout Inventory-Human Services Survey (MBI-HSS) questionnaire. Additional inquiries were made regarding demographic characteristics, occupational factors, lifestyle choices, and the Hospital Anxiety and Depression Scale (HADS) questionnaire. The survey was disseminated between March 23rd, 2023, and April 4th, 2023, utilizing the email registries of the Spanish Society of Neurosurgery (SENEC) and the Latin American Federation of Neurosurgical Societies (FLANC). Descriptive analysis was performed, comparing responses between participants with and without burnout syndrome using cross-tabulation and the Chi-square test to assess the presence of dependency. RESULTS: A total of 282 neurosurgeons completed the survey. The sample comprised 30.1% females and 69.9% males, with a median age within the 30-40 range. Among the surveyed neurosurgeons, 66.7% exhibited a prevalence of burnout, while 23.4% met the criteria for defined burnout. Significantly higher rates of burnout syndrome were observed among residents, specifically those in their fifth year of residency, as well as those whose departments perform a moderate range of surgeries (500-1000), participating in on-call duties, lacking regular physical exercise (at least twice a week), engaging infrequently in social activities with friends, lacking extracurricular hobbies, and obtaining scores exceeding 10 points in any of the HADS subscales. CONCLUSIONS: Burnout syndrome affects nearly a quarter of the neurosurgical specialists included in this study. Moreover, a distinct profile associated with defined burnout among neurosurgeons emerges, encompassing characteristics such as being a fifth-year resident, belongs to departments with a moderate number of surgeries, with few extra-occupational distractions and exhibiting symptoms of depression or anxiety.

The Integration of 3D Virtual Reality and 3D Printing Technology as Innovative Approaches to Preoperative Planning in Neuro-Oncology.

Our study explores the integration of three-dimensional (3D) virtual reality (VR) and 3D printing in neurosurgical preoperative planning. Traditionally, surgeons relied on two-dimensional (2D) imaging for complex neuroanatomy analyses, requiring significant mental visualization. Fortunately, nowadays advanced technology enables the creation of detailed 3D models from patient scans, utilizing different software. Afterwards, these models can be experienced through VR systems, offering comprehensive preoperative rehearsal opportunities. Additionally, 3D models can be 3D printed for hands-on training, therefore enhancing surgical preparedness. This technological integration transforms the paradigm of neurosurgical planning, ensuring safer procedures.

Entrenamiento microneuroquirúrgico en el espécimen anatómico. Propuesta de un plan estructurado de disección endoscópica y microquirúrgica basicraneal durante la residencia / Microneurosurgical training in the anatomical specimen: A structured plan for endoscopic and microsurgical skull base training during the residency

Antecedentes y objetivo: El desarrollo de una elevada capacidad crítica y competencia técnica constituye uno de los objetivos principales de todo programa de formación en Neurocirugía. Por múltiples factores, esta adquisición progresiva de habilidades técnicas puede resultar compleja durante la residencia. A pesar de su elevado coste y necesidad de infraestructura, existe un interés renovado respecto al papel de los laboratorios de anatomía. El estudio y disección del espécimen anatómico ha sido el contexto donde muchos neurocirujanos han desarrollado y perfeccionado la técnica microneuroquirúrgica. Proponemos un plan estructurado de disección y entrenamiento endoscópico y microquirúrgico que permita al residente obtener el máximo provecho durante su estancia en un laboratorio.Material y métodosDurante los meses de septiembre, octubre y noviembre de 2021 se realizó una estancia en el Laboratorio de Microneurocirugía y Base Craneal de la Universidad Miguel Hernández de Alicante. Se emplearon un total de 2 especímenes formolados e inyectados con silicona roja y azul. En el primer espécimen se realizó una primera fase de disección endoscópica endonasal. Tras completar la fase endonasal se plantearon un conjunto de incisiones para realizar los abordajes transcraneales. En el segundo espécimen se realizó primero la parte transcraneal dejando el trabajo endoscópico endonasal para la segunda fase.ResultadosSe muestran los resultados de la disección de los 2 especímenes. Durante la fase endoscópica endonasal se simuló el abordaje transesfenoidal a la silla incidiendo sobre los abordajes extendidos en el plano sagital. Durante la fase transcraneal se realizaron abordajes anterolaterales derecho e izquierdo, un abordaje interhemisférico transcalloso anterior izquierdo, un abordaje posterolateral transcondilar izquierdo y un abordaje lateral derecho combinado. (AU)

Background and objective: The development of a high level of competence and technical proficiency is one of the main objectives of any neurosurgical training program. Due to many factors, this progressive skill development can be complex during the residency. Despite its high cost and infrastructure requirements, there is renewed interest regarding the role of anatomy labs. The study and dissection of the human cadaver has been the environment where many surgeons have developed the necessary skills for microneurosurgery. We propose a structured endoscopic and microsurgical training dissection program to enable residents to maximize the benefits of their training in the lab.Material and methodsDuring the months of September, October and November 2021, a stay was done at the Microneurosurgery and Skull Base Laboratory of the Miguel Hernández University of Alicante. A total of 2 specimens were used. The first specimen underwent a first endoscopic endonasal dissection phase. After completing the endonasal part, a set of incisions were made to perform the transcranial part. In the second specimen, the transcranial part was performed first, leaving the endonasal endoscopic work for the last phase.ResultsThe results of the dissection program are presented. During the endonasal endoscopic phase, the transsphenoidal approach to the sella was simulated while focusing on the extended approaches in the sagittal plane. During the transcranial phase, right and left anterolateral approaches, a left anterior transcallosal interhemispheric approach, a left transcondylar posterolateral approach and a combined right lateral approach were performed. (AU)

Microneurosurgical training in the anatomical specimen: A structured plan for endoscopic and microsurgical skull base training during the residency.

BACKGROUND AND OBJECTIVE: The development of a high level of competence and technical proficiency is one of the main objectives of any neurosurgical training program. Due to many factors, this progressive skill development can be complex during the residency. Despite its high cost and infrastructure requirements, there is renewed interest regarding the role of anatomy labs. The study and dissection of the human cadaver has been the environment where many surgeons have developed the necessary skills for microneurosurgery. We propose a structured endoscopic and microsurgical training dissection program to enable residents to maximize the benefits of their training in the lab. MATERIAL AND METHODS: During the months of September, October and November 2021, a stay was done at the Microneurosurgery and Skull Base Laboratory of the Miguel Hernández University of Alicante. A total of 2 specimens were used. The first specimen underwent a first endoscopic endonasal dissection phase. After completing the endonasal part, a set of incisions were made to perform the transcranial part. In the second specimen, the transcranial part was performed first, leaving the endonasal endoscopic work for the last phase. RESULTS: The results of the dissection program are presented. During the endonasal endoscopic phase, the transsphenoidal approach to the sella was simulated while focusing on the extended approaches in the sagittal plane. During the transcranial phase, right and left anterolateral approaches, a left anterior transcallosal interhemispheric approach, a left transcondylar posterolateral approach and a combined right lateral approach were performed. CONCLUSIONS: The structured dissection of the specimen allowed both endonasal endoscopic and transcranial microsurgical training in the same specimen. This design facilitated the realization of the core skull base approaches in the same specimen. According to our initial experience, we believe that developing common dissection programs is a powerful tool to maximize the results of our residents' laboratory training.

Robot-assisted implantation of a microelectrode array in the occipital lobe as a visual prosthesis: technical note.

The prospect of direct interaction between the brain and computers has been investigated in recent decades, revealing several potential applications. One of these is sight restoration in profoundly blind people, which is based on the ability to elicit visual perceptions while directly stimulating the occipital cortex. Technological innovation has led to the development of microelectrodes implantable on the brain surface. The feasibility of implanting a microelectrode on the visual cortex has already been shown in animals, with promising results. Current research has focused on the implantation of microelectrodes into the occipital brain of blind volunteers. The technique raises several technical challenges. In this technical note, the authors suggest a safe and effective approach for robot-assisted implantation of microelectrodes in the occipital lobe for sight restoration.

Predictive model of resection in endoscopic endonasal approach for pituitary adenomas based on anatomical limits / Modelo predictivo de resección en abordaje endoscópico endonasal de adenomas hipofisarios basado en límites anatómicos

Introduction The aim of this project is to study several anatomical-radiological features of pituitary adenomas obtained from preoperative radiological images and to analyze their relationship with the extent of resection achieved through the endoscopic endonasal approach. The second objective was to create a prediction model of the extent of resection. Material and methods We retrospectively evaluated 105 patients. Tumor volume, Knosp grade, suprasellar-diaphragm coefficient and invasion of the posterior compartment have been analyzed. The extent of resection was assessed by analyzing the postoperative magnetic resonance. We created the predictive scale using statistically independent variables. Results When each of the variables has been studied individually, a statistically significant value of all of them is appreciated to obtain a complete resection. However, only the Knosp grade and the suprasellar-diaphragm coefficient had a statistically significant value as independent variables. The sum of the Odds Ratio obtained from the Knosp scale, and the suprasellar-diaphragm coefficient gives the probability of complete resection. A new set of cases was employed to validate the scale. Conclusions The cavernous sinus invasion and the newly designed suprasellar diaphragm coefficient are directly related to the extent of resection in pituitary adenoma surgery performed by a transellar endoscopic approach. Moreover, based on both radiologic factors, a predictive scale may predict the probability of complete resection in a series of patients (AU)

Introducción El objetivo principal de este proyecto es estudiar diversas variables anatomo-radiológicas de los adenomas hipofisarios obtenidas a partir de imágenes radiológicas preoperatorias y analizar su relación con el grado de resección logrado mediante el abordaje endoscopio endonasal. El segundo objetivo ha sido crear un modelo de predicción del grado de resección tumoral. Material y métodos Se ha evaluado retrospectivamente a 105 pacientes, analizando el volumen tumoral, el grado de Knosp, el coeficiente supraselar-diafragma y la invasión del compartimento posterior. El grado de resección se ha evaluado mediante el análisis de la resonancia magnética postoperatoria. Se ha creado la escala predictiva empleando variables estadísticamente independientes. Resultados Al estudiar cada una de las variables de forma individual, se aprecia un valor estadísticamente significativo en cada una de ellas para obtener una resección completa. Sin embargo, tan solo el grado de Knosp y el coeficiente supraselar-diafragma tuvieron un valor estadísticamente significativo como variables independientes. Empleando la suma de la odds ratio obtenida de la escala Knosp y el coeficiente supraselar-diafragma, se ha obtenido la probabilidad de resección completa. Se ha empleado un nuevo conjunto de casos para validar la escala. Conclusiones La invasión del seno cavernoso y el coeficiente supraselar-diafragma son variables que están directamente relacionadas con el grado de resección en la cirugía de adenoma hipofisario realizada mediante un abordaje endoscópico transellar. Además, basándose en ambos factores radiológicos, se ha creado una escala predictiva que permite predecir la probabilidad de resección completa en una serie de pacientes (AU)

Predictive model of resection in endoscopic endonasal approach for pituitary adenomas based on anatomical limits.

INTRODUCTION: The aim of this project is to study several anatomical-radiological features of pituitary adenomas obtained from preoperative radiological images and to analyze their relationship with the extent of resection achieved through the endoscopic endonasal approach. The second objective was to create a prediction model of the extent of resection. MATERIAL AND METHODS: We retrospectively evaluated 105 patients. Tumor volume, Knosp grade, suprasellar-diaphragm coefficient and invasion of the posterior compartment have been analyzed. The extent of resection was assessed by analyzing the postoperative magnetic resonance. We created the predictive scale using statistically independent variables. RESULTS: When each of the variables has been studied individually, a statistically significant value of all of them is appreciated to obtain a complete resection. However, only the Knosp grade and the suprasellar-diaphragm coefficient had a statistically significant value as independent variables. The sum of the Odds Ratio obtained from the Knosp scale, and the suprasellar-diaphragm coefficient gives the probability of complete resection. A new set of cases was employed to validate the scale. CONCLUSIONS: The cavernous sinus invasion and the newly designed suprasellar diaphragm coefficient are directly related to the extent of resection in pituitary adenoma surgery performed by a transellar endoscopic approach. Moreover, based on both radiologic factors, a predictive scale may predict the probability of complete resection in a series of patients.

Three-Dimensional Reconstruction of the Sphenoid Sinus Anatomy for Presurgical Planning with Free OSIRIX Software.

Background A preoperative three-dimensional (3D) surgical field understanding remains a key factor to achieve safer endonasal transsphenoidal endoscopic approaches (ETSE). The aim of this article is to describe how we can get a reliable 3D sphenoidal anatomical reconstruction for surgical planning by using a user-friendly, accurate, and free image software. Methods Free computer software (OSIRIX Medical Imaging Software) was used to create in a personal computer a three-dimensional (3D) reconstruction of the sphenoid sinus (SS) based on head computed tomography angiographies (CTAs) from a series of 67 patients who were operated for sellar tumors during a 4-year period (March 2016 to March 2020). The aim of the 3D reconstruction with OSIRIX was to reveal preoperatively the most important intrasphenoidal structures seen from the endonasal point of view. Results The intraoperative visible sphenoidal structures were previously recognized in the virtual 3D reconstructed image with 100% of specificity (SP) and positive predictive value. The OSIRIX view by using region of interest points allowed us to see preoperatively the internal carotid artery parasellar course even in those cases in which it was hidden by bone or tumor. Moreover, the 3D reconstruction was able to provide a clear differentiation between the tumor and the pituitary gland when both structures were in contact with the sellar floor. Conclusion Our experience with the OSIRIX software from CTA as preoperative planning for endonasal pituitary surgery was valuable, because it gave us access in simple way to a free and reliable 3D image of the SS.

3D Stereoscopic View in Neurosurgical Anatomy: Compilation of Basic Methods.

BACKGROUND: Stereoscopy has been demonstrated to be a useful method of education in the field of anatomy because it allows users to see, in a simulation, the anatomical structures in their actual volume and depth. METHODS: Cadaveric specimens preserved under formaldehyde using the Thiel and Klinger techniques have been dissected and photographed in the medical school anatomy laboratory (University Miguel Hernández) for the past 10 years. The photographic material and technique required to capture and project stereoscopic photographs have been described in different fields of surgical neuroanatomy. We used the results from a survey completed by the participants of different training courses to evaluate the utility of the 3-dimensional (3D) method. RESULTS: A large database of photographs taken of different anatomical regions and approaches of neurosurgical interest was obtained. We have presented some examples in the form of pairs of photographs in 2-dimensional (2D) format, with explanatory labels, paired with the corresponding 3D photograph in anaglyph format. The survey showed that the lectures that had included 3D photographs were significantly better accepted than the lectures with conventional 2D photographs. CONCLUSIONS: The teaching of basic, academic, and clinical neuroanatomy through the projection of stereoscopic photographs can be useful. The methods of image capture and stereoscopic projection in neuroanatomy, once combined with the necessary theoretical and practical knowledge, can be reproduced at other centers of neuroanatomy teaching.

Research in Cerebrospinal Fluid Leak (Rhinorrhea and Otorrhea): A Bibliometric Analysis From 1945 to 2018.

Objective In this study, we aimed to analyze research activity on cerebrospinal fluid (CSF) leaks in general and CSF rhinorrhea and otorrhea in particular and to identify the main topic clusters in these areas. Methods We identified all relevant documents, using the medical subject heading (MeSH) term "Cerebrospinal Fluid Leak", that are indexed in the MEDLINE database between 1945 and 2018. We performed a descriptive bibliometric analysis and analyses of networks and research clusters in order to identify the main topic areas of research. Results From 1945 to 2018, a total of 4,130 records were published with the term CSF leak, including 2,821 documents (68.1%) with the term CSF rhinorrhea and 1,040 documents (25.8%) with CSF otorrhea. The number of documents published increased from 10 in 1945-49 to 642 in 2010-14. Articles represented the dominant document type (86.8% of the documents analyzed), while case reports were the main type of study (37.4%). In terms of geographical distribution, researchers from the USA led in the number of signatures (39.1%), followed by those from the UK (7.5%). The most active areas of research in the field were "Postoperative Complications," "Tomography, X-Ray Computed," and "Magnetic Resonance Imaging." The terms "Adults," "Young Adult," and "Middle-Aged" were most common in CSF rhinorrhea research; and the terms "Infant," "Child, Preschool," "Child," and "Adolescent" were more common in CSF otorrhea. Conclusions Based on our findings, articles and case reports related to "Surgery" and "Postoperative Complications" associated with the diagnosis are the main topics of study, highlighting the importance of this document type in advancing knowledge in the field.

How I do it: paramedian supracerebellar transtentorial approach for a temporomesial glioma.

BACKGROUND: Classical approaches to the temporomesial region (TMR) include transtemporal, transylvian, or subtemporal. The supracerebellar infratentorial, initially developed to access dorsolateral cavernomas, has of late shown its versatility to access areas around the central core. The TMR is one such area that can be accessed through this approach with the addition of a tentorial incision. METHOD: The paramedian supracerebellar transtentorial approach (PSCTA) is described along with its advantages and limits compared to other approaches to treat TMR gliomas. CONCLUSION: The PSCTA offers a basal panoramic view of the TMR without the need of retraction, cortical incision, and white matter transgression.

Three-Dimensional Microscopic Surgical Videos: A Novel and Low-cost System.

INTRODUCTION: Three-dimensional (3D) imaging and videos are a very useful tool in the neurosurgical training, although unfortunately the 3D systems available have a very high cost. The objective of this study is to describe a novel and low-cost 3D microsurgical video system. METHODS: To obtain the 3D videos we use a surgical microscope, 2 video adapters, 2 cameras, and an HDMI cable. A video editor program is used for processing the videos. For the projection we use a computer with PowerPoint (Microsoft, Inc, Redmond, WA) software, a video splitter, DVI cables, 2 projectors, 2 polarization filters, and a "silver screen" with polarized glasses. RESULTS: By using 2 equal cameras and video adaptors in each beam splitter port it was possible for us to obtain 2 videos that were equivalent to the images received by both surgeon's eyes. Using the video signal of both cameras during processing resulted in a 3D stereoscopic recording with Final Cut (Apple, Inc, Cupertino, CA) software. The polarized 3D format provided the best projection conditions. It does not alter the original colors of the videos and its prolonged visualization was more comfortable. The main advantage of this method is the ability to show in a realistic way the spatial relationships and the depth of the structures captured with the microscope. CONCLUSIONS: This paper presents in a clear and detailed way how to create and use a low-cost 3D surgical video system.

Endonasal Endoscopic and Transoral Approaches to the Craniovertebral Junction and the Clival Region: A Comparative Anatomical Study.

OBJECTIVE: Anterior craniovertebral junction (CVJ) surgery has continued to be one of the most debated neurosurgical topics. The transoral approach (TOA) has been considered the choice for this region. However, it has some limitations and a not negligible degree of surgery-related morbidity. With the advent of endoscopy, the endoscopic endonasal approach (EEA) was developed, which minimized morbidity and improved exposure. To the best of our knowledge, despite the extensive reported data, a comparative anatomical study has not been performed and no definitive consensus has been reached on the indications for both approaches. METHODS: We compared the TOA and EEA to the CVJ using the previously described operability score (OS), calculated at 4 different targets: the C1 tubercle (C1), the lowest exposed point of the odontoid process (C2), the basion (BS) and the middle clivus (MC). The higher the OS for the selected targets, the more favorable the approach. RESULTS: The TOA had higher OSs at the MC, C1, and C2 targets, and the EEA showed greater OSs at MC and C1. The TOA and EEA had similar OSs at the BS. These results have shown that the OS is more favorable at C1-C2 using the TOA and the OSs at the MC and BS were similar. CONCLUSIONS: The OS is an effective method to compare surgical approaches. The present study demonstrated the maximal exposure capability of the 2 approaches. The TOA seemed to be superior for lower targets and the EEA for upper targets. Because of the strong variability in the CVJ anatomy and pathological features, we suggest considering the OS as a further tool to better define the best surgical approach.

Cirugía endoscópica endonasal en adenomas hipofisarios: resultados quirúrgicos en una serie de 86 pacientes consecutivos / Endonasal endoscopic surgery in pituitary adenomas: Surgical results in a series of 86 consecutive patients

Introducción: El abordaje endoscópico endonasal se ha convertido en la técnica quirúrgica de elección para el tratamiento de los adenomas hipofisarios. Objetivos: El objetivo de este trabajo es presentar los resultados obtenidos en nuestro hospital en cirugía puramente endoscópica de los adenomas hipofisarios. Métodos: Hemos realizado un estudio prospectivo, recogiendo a los pacientes intervenidos de adenoma hipofisario mediante un abordaje endonasal puramente endoscópico, desde febrero de 2011 hasta agosto de 2016, obteniendo una muestra total de 86 pacientes. Todos los pacientes fueron intervenidos conjuntamente por un ORL y un neurocirujano con la técnica de four hands-two nostrils. El seguimiento medio postoperatorio fue de 32 meses. Todos los pacientes fueron evaluados según criterios clínicos, radiológicos y endocrinológicos. Resultados: En nuestra serie un 53% eran mujeres y un 47% hombres; el rango de edad variaba desde los 14 hasta los 84 años, siendo la media de 54 años. El síntoma inicial más habitual fue el déficit visual (42%), seguido por la hiperfunción hormonal (21%), siendo la acromegalia el síndrome clínico observado con más frecuencia. Los tumores más frecuentes fueron los no funcionantes (73%), y de entre los adenomas funcionantes el más frecuente fue el productor de GH (65%). En cuanto a tamaño tumoral, un 76% eran macroadenomas, un 11% microadenomas y un 13% gigantes. Un 63% presentaban extensión supraselar y un 37% invasión de seno cavernoso (grado de Knosp ≥3). Se consiguió una exéresis total en un 77% de los casos. Tras la intervención se consiguió en un 91% mejoría visual y hasta en un 73% remisión de la hiperfunción endocrina. En cuanto a las complicaciones, la más frecuente fue la insuficiencia de al menos un eje de la hipófisis anterior (9%), sin presentar casos de fístula de LCR posquirúrgica. Conclusiones: Nuestros resultados, en términos de calidad quirúrgica, se asemejan a las series publicadas y avalan la eficacia y seguridad del abordaje endoscópico endonasal como técnica de elección en el manejo quirúrgico de la glándula hipofisaria. Sin embargo, es necesario un estudio con mayor número de casos para obtener resultados con significación clínica

Introduction: The endoscopic endonasal approach has become the gold standard for the surgical treatment of pituitary adenomas. Objectives: The aim of this study is to present the results obtained in our hospital in purely endoscopic surgery of pituitary adenomas. Methods: From February 2011 to August 2016, we conducted a prospective study on a series of 86 patients with pituitary adenoma, all of whom underwent surgery with a purely endoscopic endonasal approach. The ‘four hands-two nostrils’ technique was performed in all cases by a surgical team composed of an ENT surgeon and a neurosurgeon. Mean follow-up was 32 months. All patients were evaluated according to clinical, radiological and endocrinological criteria. Results: In our series, 53% were women and 47% men. The age ranged from 14 to 84 years of age, with a mean of 54 years of age. The most common initial symptom was visual deficit (42%), followed by hormonal hyperfunction (21%), with acromegaly being the most common clinical syndrome. The most common tumours were non-functioning tumours (73%), while GH-secreting tumours (65%) were the most common functioning adenoma. Regarding tumour size, 76% were macroadenomas, 11% microadenomas and 13% giant adenomas. Approximately 63% of the adenomas exhibited suprasellar extension and 37% involved invasion of the cavernous sinus (Knosp grade ≥3). Total excision was achieved in 77% of the cases. After the intervention, visual improvement was achieved in 91% and remission of endocrine hyperfunction in up to a 73% of cases. The most common complication was anterior pituitary insufficiency of at least one axis (9%). There were no cases of postoperative cerebrospinal fluid fistula. Conclusions: In terms of surgical quality, our results are similar to those of published series, and demonstrate the efficacy and safety of the endoscopic endonasal approach as the surgical treatment of choice for pituitary adenomas. However, further studies with a higher sample size are necessary to obtain clinically significant results

[Endonasal endoscopic surgery in pituitary adenomas: Surgical results in a series of 86 consecutive patients]. / Cirugía endoscópica endonasal en adenomas hipofisarios: resultados quirúrgicos en una serie de 86 pacientes consecutivos.

INTRODUCTION: The endoscopic endonasal approach has become the gold standard for the surgical treatment of pituitary adenomas. OBJECTIVES: The aim of this study is to present the results obtained in our hospital in purely endoscopic surgery of pituitary adenomas. METHODS: From February 2011 to August 2016, we conducted a prospective study on a series of 86 patients with pituitary adenoma, all of whom underwent surgery with a purely endoscopic endonasal approach. The 'four hands-two nostrils' technique was performed in all cases by a surgical team composed of an ENT surgeon and a neurosurgeon. Mean follow-up was 32 months. All patients were evaluated according to clinical, radiological and endocrinological criteria. RESULTS: In our series, 53% were women and 47% men. The age ranged from 14 to 84 years of age, with a mean of 54 years of age. The most common initial symptom was visual deficit (42%), followed by hormonal hyperfunction (21%), with acromegaly being the most common clinical syndrome. The most common tumours were non-functioning tumours (73%), while GH-secreting tumours (65%) were the most common functioning adenoma. Regarding tumour size, 76% were macroadenomas, 11% microadenomas and 13% giant adenomas. Approximately 63% of the adenomas exhibited suprasellar extension and 37% involved invasion of the cavernous sinus (Knosp grade ≥3). Total excision was achieved in 77% of the cases. After the intervention, visual improvement was achieved in 91% and remission of endocrine hyperfunction in up to a 73% of cases. The most common complication was anterior pituitary insufficiency of at least one axis (9%). There were no cases of postoperative cerebrospinal fluid fistula. CONCLUSIONS: In terms of surgical quality, our results are similar to those of published series, and demonstrate the efficacy and safety of the endoscopic endonasal approach as the surgical treatment of choice for pituitary adenomas. However, further studies with a higher sample size are necessary to obtain clinically significant results.

Transsphenoidal Approach in Endoscopic Endonasal Surgery for Skull Base Lesions: What Radiologists and Surgeons Need to Know.

In the last 2 decades, endoscopic endonasal transsphenoidal surgery has become the most popular choice of neurosurgeons and otolaryngologists to treat lesions of the skull base, with minimal invasiveness, lower incidence of complications, and lower morbidity and mortality rates compared with traditional approaches. The transsphenoidal route is the surgical approach of choice for most sellar tumors because of the relationship of the sphenoid bone to the nasal cavity below and the pituitary gland above. More recently, extended approaches have expanded the indications for transsphenoidal surgery by using different corridors leading to specific target areas, from the crista galli to the spinomedullary junction. Computer-assisted surgery is an evolving technology that allows real-time anatomic navigation during endoscopic surgery by linking preoperative triplanar radiologic images and intraoperative endoscopic views, thus helping the surgeon avoid damage to vital structures. Preoperative computed tomography is the preferred modality to show bone landmarks and vascular structures. Radiologists play an important role in surgical planning by reporting extension of sphenoid pneumatization, recesses and septations of the sinus, and other relevant anatomic variants. Radiologists should understand the relationships of the sphenoid bone and skull base structures, anatomic variants, and image-guided neuronavigation techniques to prevent surgical complications and allow effective treatment of skull base lesions with the endoscopic endonasal transsphenoidal approach.

Estudio endoscópico endonasal 3D de la anatomía de la base de cráneo / Three-dimensional endoscopic endonasal study of skull base anatomy

INTRODUCCIÓN: El entrenamiento en la disección de los senos paranasales y la base de cráneo es esencial para el conocimiento anatómico y la correcta aplicación de las técnicas quirúrgicas. La visualización tridimensional de la anatomía endoscópica de la base de cráneo mejora la orientación espacial y permite la percepción de profundidad. OBJETIVO: Mostrar la anatomía endoscópica de la base de cráneo basándose en la técnica tridimensional. MÉTODOS: Realizamos disección endoscópica endonasal en especímenes cadavéricos fijados con formol y con la técnica de Thiel, ambos con inyección intravascular de colorantes. Los abordajes fueron realizados con endoscopios convencionales 2D. Posteriormente aplicamos la técnica 3D anaglífica para ilustrar las figuras en 3D. RESULTADOS: Se ilustran las más importantes estructuras y referencias anatómicas de la región selar desde la perspectiva endonasal endoscópica en 3D. CONCLUSIÓN: La base del cráneo está compuesta por complejas estructuras óseas y neurovasculares. La experiencia con la disección en cadáver es crucial para comprender la anatomía y desarrollar habilidades quirúrgicas. La visualización 3D representa una útil herramienta para comprender la anatomía de la base de cráneo

INTRODUCTION: Training in dissection of the paranasal sinuses and the skull base is essential for anatomical understanding and correct surgical techniques. Three-dimensional (3D) visualisation of endoscopic skull base anatomy increases spatial orientation and allows depthperception. OBJECTIVE: To show endoscopic skull base anatomy based on the 3D technique. METHODS: We performed endoscopic dissection in cadaveric specimens fixed with formalin and with the Thiel technique, both prepared using intravascular injection of coloured material. Endonasal approaches were performed with conventional 2D endoscopes. Then we applied the 3D anaglyph technique to illustrate the pictures in 3D. RESULTS: The mostimportant anatomical structures and landmarks of the sellar region underendonasal endoscopic vision are illustrated in 3D images. CONCLUSION: The skull base consists of complex bony and neurovascular structures. Experience with cadaver dissection is essential to understand complex anatomy and developsurgical skills. A 3D view constitutes a useful tool for understanding skull base anatomy

[Three-dimensional endoscopic endonasal study of skull base anatomy]. / Estudio endoscópico endonasal 3D de la anatomía de la base de cráneo.

INTRODUCTION: Training in dissection of the paranasal sinuses and the skull base is essential for anatomical understanding and correct surgical techniques. Three-dimensional (3D) visualisation of endoscopic skull base anatomy increases spatial orientation and allows depth perception. OBJECTIVE: To show endoscopic skull base anatomy based on the 3D technique. METHODS: We performed endoscopic dissection in cadaveric specimens fixed with formalin and with the Thiel technique, both prepared using intravascular injection of coloured material. Endonasal approaches were performed with conventional 2D endoscopes. Then we applied the 3D anaglyph technique to illustrate the pictures in 3D. RESULTS: The most important anatomical structures and landmarks of the sellar region under endonasal endoscopic vision are illustrated in 3D images. CONCLUSION: The skull base consists of complex bony and neurovascular structures. Experience with cadaver dissection is essential to understand complex anatomy and develop surgical skills. A 3D view constitutes a useful tool for understanding skull base anatomy.

Anatomía radiológica de las arterias etmoidales: estudio por TC en cadáver / Radiological anatomy of the ethmoidal arteries: CT cadaver study

Introducción y objetivos: El objetivo del trabajo es realizar un estudio de la anatomía radiológica de las arterias etmoidales. Métodos: Se realizó un estudio descriptivo con imágenes de tomografía computarizada correspondientes a 20 cabezas de cadáver perfundidas con material radiopaco. Se analizaron diferentes parámetros anatómicos. Resultados: La arteria etmoidal anterior se localizó en el 95% (38/40) de los casos. En el 87,55% (35/40) de las fosas se originó de la arteria oftálmica, encontrando en seis casos variantes de la normalidad. La longitud media del canal etmoidal anterior fue de 8,43±0,74mm con un ángulo de entrada en la base de cráneo de 37,3±5,48º. En el 90% de los casos (36/40), se localizó entre la segunda y la tercera lamela. La arteria etmoidal posterior sólo pudo localizarse en (14/40) fosas nasales. El 28,5% (4/14) presentaron variantes en su origen. La longitud media del canal etmoidal posterior fue de 7,1±1,02mm realizando un ángulo anterior a su salida de la órbita de 7,11±4,07º La distancia desde la espina nasal hasta la arteria etmoidal anterior fue de 55,51±5,52mm. El ángulo realizado entre la espina nasal y el canal etmoidal anterior fue de 57,67±1,68º. La distancia entre el nasión y el canal etmoidal anterior fue de 29,31±2,53mm, de la arteria etmoidal anterior a la arteria etmoidal posterior fue de 11,24±2,14mm y de la arteria etmoidal posterior al nervio óptico de 7,26±1,33mm. Se apreciaron celdas supraorbitarias en el 15% (6/40) de las fosas. Conclusiones: La técnica utilizada permitió realizar un análisis vascular completo del trayecto de las arterias etmoidales (AU)

Introduction and objectives: Our aim was to study the radiological anatomy of the ethmoidalarteries. Methods: A descriptive study was performed including CT images of 20 cadaver heads. The specimens were perfused with a radiopaque material and various anatomical parameters were analysed. Results: The anterior ethmoidal artery was found in 95% (38/40) of cases. It originated from the ophthalmic artery in 87.5% (34/40) of nasal cavities. In six cases, normal variants were found. The mean length of the anterior ethmoidal canal was 8.43±0.74mm. The angle performed into the skull base was 37.3±5.48º. In 90% of cases (36/40), it was located between the second and third lamella. The posterior ethmoidal artery was localised only in 14/40 cases, with 28.5% (4/14) of them showing normal variants. The mean length of the posterior ethmoidal canal was 7.1±1.02mm. The angle performed into the skull base was 7.11±4.07º. The distance from sill to the anterior ethmoid artery was 55.51±5.52mm. The angle between the nasalspine and the anterior ethmoidal canal was 57.67±1.68º. The distance between the nasion and the anterior ethmoidal canal was 29.31±2.53mm, the distance was 11.24±2.14mm from the anterior ethmoid artery to the posterior ethmoid artery and from the posterior ethmoid artery to the optic nerve, 7.26±1.33mm. Supraorbital cells were observed in 15% (6/40) of the cases. Conclusions: A complete vascular study of the ethmoidal arteries was possible by using this technique (AU)

[Radiological anatomy of the ethmoidal arteries: CT cadaver study]. / Anatomía radiológica de las arterias etmoidales: estudio por TC en cadáver.

INTRODUCTION AND OBJECTIVES: Our aim was to study the radiological anatomy of the ethmoidal arteries. METHODS: A descriptive study was performed including CT images of 20 cadaver heads. The specimens were perfused with a radiopaque material and various anatomical parameters were analysed. RESULTS: The anterior ethmoidal artery was found in 95% (38/40) of cases. It originated from the ophthalmic artery in 87.5% (34/40) of nasal cavities. In six cases, normal variants were found. The mean length of the anterior ethmoidal canal was 8.43 ± 0.74 mm. The angle performed into the skull base was 37.3 ± 5.48°. In 90% of cases (36/40), it was located between the second and third lamella. The posterior ethmoidal artery was localised only in 14/40 cases, with 28.5% (4/14) of them showing normal variants. The mean length of the posterior ethmoidal canal was 7.1 ± 1.02 mm. The angle performed into the skull base was 7.11 ± 4.07°. The distance from sill to the anterior ethmoid artery was 55.51 ± 5.52 mm. The angle between the nasal spine and the anterior ethmoidal canal was 57.67 ± 1.68°. The distance between the nasion and the anterior ethmoidal canal was 29.31 ± 2.53 mm, the distance was 11.24 ± 2.14 mm from the anterior ethmoid artery to the posterior ethmoid artery and from the posterior ethmoid artery to the optic nerve, 7.26 ± 1.33 mm. Supraorbital cells were observed in 15% (6/40) of the cases. CONCLUSIONS: A complete vascular study of the ethmoidal arteries was possible by using this technique.