RESUMO
Spinal fixation with rigid pedicle screws have shown to be an effective treatment for many patients. However, this surgical option has been proved to be insufficient and will eventually fail for patients experiencing osteoporosis. This failure is mainly attributed to the lack of dexterity in the existing rigid drilling instruments and the complex anatomy of vertebrae, forcing surgeons to implant rigid pedicle screws within the osteoporotic regions of anatomy. To address this problem, in this article, we present the design, fabrication, and evaluation of a unique flexible yet structurally strong concentric tube steerable drilling robot (CT-SDR). The CT-SDR is capable of drilling smooth and accurate curved trajectories through hard tissues without experiencing buckling and failure; thus enabling the use of novel flexible pedicle screws for the next generation of spinal fixation procedures. Particularly, by decoupling the control of bending and insertion degrees of freedom (DoF) of the CT-SDR, we present a robotic system that (i) is intuitive to steer as it does not require an on-the-fly control algorithm for the bending DoF, and (ii) is able to address the contradictory requirements of structural stiffness and dexterity of a flexible robot interacting with the hard tissue. The robust and repeatable performance of the proposed CT-SDR have been experimentally evaluated by conducting various drilling procedures on simulated bone materials and animal bone samples. Experimental results indicate drilling times as low as 35 seconds for curved trajectories with 41 mm length and remarkable steering accuracy with a maximum 2% deviation error.
Assuntos
Parafusos Pediculares , Procedimentos Cirúrgicos Robóticos , Robótica , Fusão Vertebral , Cirurgia Assistida por Computador , Animais , Humanos , Vértebras Lombares/cirurgia , Cirurgia Assistida por Computador/métodos , Fusão Vertebral/efeitos adversos , Fusão Vertebral/métodosRESUMO
BACKGROUND: Whether magnetic resonance imaging (MRI) adds value to surgical planning for patients with acute traumatic cervical spinal cord injury (ATCSCI) remains controversial. In this study, we compared surgeons' operative planning decisions with and without preoperative MRI. We had two hypotheses: (1) the surgical plan for ATCSCI would not change substantially after the MRI and (2) intersurgeon agreement on the surgical plan would also not change substantially after the MRI. METHODS: We performed a vignette-based survey study that included a retrospective review of all adult trauma patients who presented to our American College of Surgeons-verified level 1 trauma center from 2010 to 2019 with signs of acute quadriplegia and underwent computed tomography (CT), MRI, and subsequent cervical spine surgery within 48 hours of admission. We abstracted patient demographics, admission physiology, and injury details. Patient clinical scenarios were presented to three spine surgeons, first with only the CT and then, a minimum of 2 weeks later, with both the CT and MRI. At each presentation, the surgeons identified their surgical plan, which included timing (none, <8, <24, >24 hours), approach (anterior, posterior, circumferential), and targeted vertebral levels. The outcomes were change in surgical plan and intersurgeon agreement. We used Fleiss' kappa (κ) to measure intersurgeon agreement. RESULTS: Twenty-nine patients met the criteria and were included. Ninety-three percent of the surgical plans were changed after the MRI. Intersurgeon agreement was "slight" to "fair" both before the MRI (timing, κ = 0.22; approach, κ = 0.35; levels, κ = 0.13) and after the MRI (timing, κ = 0.06; approach, κ = 0.27; levels, κ = 0.10). CONCLUSION: Surgical plans for ATCSCI changed substantially when the MRI was presented in addition to the CT; however, intersurgeon agreement regarding the surgical plan was low and not improved by the addition of the MRI. LEVEL OF EVIDENCE: Diagnostic, level II.
Assuntos
Medula Cervical/lesões , Vértebras Cervicais , Traumatismos da Medula Espinal/diagnóstico por imagem , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Medula Cervical/diagnóstico por imagem , Medula Cervical/cirurgia , Vértebras Cervicais/lesões , Vértebras Cervicais/cirurgia , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Período Pré-Operatório , Estudos Retrospectivos , Traumatismos da Medula Espinal/cirurgia , Fatores de Tempo , Tomografia Computadorizada por Raios X , Adulto JovemRESUMO
BACKGROUND: Posterior reversible leukoencephalopathy syndrome (PRES) is linked to various etiologies, including most importantly systemic hypertension. Its association with intracranial hypotension (IH), a potential sequela of various neurosurgical procedures, is underrecognized. We report a case of lumboperitoneal shunt-induced IH resulting in PRES with the goal to increase awareness and elaborate on the potential biologic mechanism, based on the Monro-Kellie hypothesis. CASE DESCRIPTION: A 26-year-old woman with acquired immunodeficiency syndrome and epilepsy was admitted for recurrent cryptococcal meningitis and breakthrough seizures. There was radiologic evidence of ventricular enlargement, and opening pressure on serial lumbar punctures was constantly elevated. Owing to persistently elevated, symptomatic intracranial pressure and transient relief with serial lumbar punctures, a lumboperitoneal shunt was placed. The patient subsequently had a breakthrough seizure and became encephalopathic. Repeat head imaging showed reduced ventricular size, engorged venous sinuses, and tonsillar herniation in keeping with IH, coupled with extensive white matter abnormalities in bilateral parieto-occipital lobes indicative of PRES. The patient had an emergent programmable valve placed in the lumboperitoneal shunt to prevent excessive cerebrospinal fluid drainage, leading to clinical and radiologic improvement. Subsequent cerebrospinal fluid leak resulted in recurrent presentation. CONCLUSIONS: IH appears to be a distinct cause of PRES not previously reported in the neurosurgical literature. It occurs in susceptible patients, on average 1-5 days after the IH trigger, and seems clinically and radiologically similar to more common hypertensive cases in terms of initial presentation and prognosis. Increased vigilance is required for prompt recognition and management.
Assuntos
Derivações do Líquido Cefalorraquidiano/efeitos adversos , Hipotensão Intracraniana/cirurgia , Síndrome da Leucoencefalopatia Posterior/etiologia , Adulto , Vazamento de Líquido Cefalorraquidiano/diagnóstico por imagem , Vazamento de Líquido Cefalorraquidiano/cirurgia , Feminino , Humanos , Hipotensão Intracraniana/complicações , Hipotensão Intracraniana/diagnóstico por imagem , Hipotensão Intracraniana/etiologia , Imageamento por Ressonância Magnética , Síndrome da Leucoencefalopatia Posterior/diagnóstico por imagem , Tomógrafos ComputadorizadosRESUMO
Neurosurgery journals have played an active role in improving the quality of the neurosurgical literature. This role has expanded to improve the quality of care by incorporating an evidence-based view of neurosurgery practice. Neurosurgery journals have facilitated the organization of knowledge into clinically useful forms via the publication of meta-analyses and dissemination of clinical practice guidelines. Peer review continues to be a core feature of neurosurgery publishing, with attendant ethical and procedural safeguards. Finally, neurosurgery journals have spearheaded innovative responses to cultural and technological changes, including initiatives to deliver high-quality research in electronic formats and support the education of future neurosurgery investigators.
Assuntos
Medicina Baseada em Evidências/tendências , Neurocirurgia/tendências , Publicações Periódicas como Assunto , Humanos , Guias de Prática Clínica como AssuntoRESUMO
OBJECT: Robotics in the operating room has shown great use and versatility in multiple surgical fields. Robot-assisted spine surgery has gained significant favor over its relatively short existence, due to its intuitive promise of higher surgical accuracy and better outcomes with fewer complications. Here, the authors analyze the existing literature on this growing technology in the era of minimally invasive spine surgery. METHODS: In an attempt to provide the most recent, up-to-date review of the current literature on robotic spine surgery, a search of the existing literature was conducted to obtain all relevant studies on robotics as it relates to its application in spine surgery and other interventions. RESULTS: In all, 45 articles were included in the analysis. The authors discuss the current status of this technology and its potential in multiple arenas of spinal interventions, mainly spine surgery and spine biomechanics testing. CONCLUSIONS: There are numerous potential advantages and limitations to robotic spine surgery, as suggested in published case reports and in retrospective and prospective studies. Randomized controlled trials are few in number and show conflicting results regarding accuracy. The present limitations may be surmountable with future technological improvements, greater surgeon experience, reduced cost, improved operating room dynamics, and more training of surgical team members. Given the promise of robotics for improvements in spine surgery and spine biomechanics testing, more studies are needed to further explore the applicability of this technology in the spinal operating room. Due to the significant cost of the robotic equipment, studies are needed to substantiate that the increased equipment costs will result in significant benefits that will justify the expense.
Assuntos
Procedimentos Cirúrgicos Minimamente Invasivos/instrumentação , Robótica/instrumentação , Coluna Vertebral/cirurgia , Cirurgia Assistida por Computador/economia , Cirurgia Assistida por Computador/instrumentação , Humanos , Procedimentos Cirúrgicos Minimamente Invasivos/economia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Despite an ever-expanding database of sequenced mammalian genomes to be mined for clues, the emergence of the unique human brain remains an evolutionary enigma. In their new study, trawl the human genome and those of other mammals in search of short conserved DNA elements that show extremely rapid evolution only in humans. As they report in a recent issue of Nature, their scan yielded a gene for a novel noncoding RNA that adopts a human-specific structure and may regulate neurodevelopment.