Study protocol for a multicenter randomized controlled pilot study on decompressive laparotomy vs. decompressive craniectomy for intractable intracranial pressure after traumatic brain injury: The SCALPEL study.

Introduction: Decompressive craniectomy (DC) is the ultimate intervention to lower intracranial pressure (ICP) following severe traumatic brain injury (TBI). However, this intervention is associated with considerable adverse events and a higher proportion of survivors with poor functional outcomes. Research question: In a multicompartment system ICP is associated with intraabdominal pressure (IAP) due to cerebral venous outflow from the brain. This is the rationale for decompressive laparotomy (DL) to control ICP after TBI as reported by experimental and retrospective clinical data. The safety profile of DL is superior to DC. This study aims to randomly assign patients with intractable high ICP after severe TBI to DL or DC. Material and methods: Among other inclusion criteria, ICP must be above 20 mmHg (1-12 h) despite sedation and all other measures according to current guidelines. The primary outcome is the Extended Glasgow Outcome Scale assessed after twelve months. Further secondary outcome measures are compartmental pressure values, complications, etc. After 20 initial patients, results will be reviewed by the ethics committees and safety monitoring board to decide on the enrolment of 80 additional patients. Results: The study is designed to provide not only high-quality prospective data for the first time on this treatment approach, its two-stage design (20 + 80 pts) also provides maximum patient safety. This protocol conforms with the SPIRIT 2013 Statement. Ethics approval was granted by our but also 5 other university ethics committees (registration 473/18S). Conclusion: Registration was performed prior to study initiation in November 2021 (registration number NCT05115929).

Development and first results of a national databank on care and treatment outcome after traumatic brain injury.

PURPOSE: In absence of comprehensive data collection on traumatic brain injury (TBI), the German Society for Neurosurgery (DGNC) and the German Society for Trauma Surgery (DGU) developed a TBI databank for German-speaking countries. METHODS: From 2016 to 2020, the TBI databank DGNC/DGU was implemented as a module of the TraumaRegister (TR) DGU and tested in a 15-month pilot phase. Since its official launch in 2021, patients from the TR-DGU (intermediate or intensive care unit admission via shock room) with TBI (AIS head ≥ 1) can be enrolled. A data set of > 300 clinical, imaging, and laboratory variables, harmonized with other international TBI data collection structures is documented, and the treatment outcome is evaluated after 6- and 12 months. RESULTS: For this analysis, 318 patients in the TBI databank could be included (median age 58 years; 71% men). Falls were the most common cause of injury (55%), and antithrombotic medication was frequent (28%). Severe or moderate TBI were only present in 55% of patients, while 45% suffered a mild injury. Nevertheless, intracranial pathologies were present in 95% of brain imaging with traumatic subarachnoid hemorrhages (76%) being the most common. Intracranial surgeries were performed in 42% of cases. In-hospital mortality after TBI was 21% and surviving patients could be discharged after a median hospital stay of 11 days. At the 6-and 12 months follow-up, a favorable outcome was achieved by 70% and 90% of the participating TBI patients, respectively. Compared to a European cohort of 2138 TBI patients treated in the ICU between 2014 and 2017, patients in the TBI databank were already older, frailer, fell more commonly at home. CONCLUSION: Within five years, the TBI databank DGNC/DGU of the TR-DGU could be established and is since then prospectively enrolling TBI patients in German-speaking countries. With its large and harmonized data set and a 12-month follow-up, the TBI databank is a unique project in Europe, already allowing comparisons to other data collection structures and indicating a demographic change towards older and frailer TBI patients in Germany.

Spindle cell oncocytoma of the neurohypophysis with metastasis to the sphenoparietal sinus and immunohistochemical negativity for S100 and epithelial membrane antigen (EMA).

We report the case of a 61-year-old male with spindle cell oncocytoma of the hypophysis. On presentation to the Department of Neurosurgery at the German Armed Forces Hospital of Ulm, the patient reported a history of several years of left sixth nerve palsy, right ptosis, increased sensitivity to light, and a bilateral retrobulbar pressure sensation. Pituitary function was normal. A chromophobe non-functioning pituitary adenoma was initially suspected. The diagnosis was established on the basis of examination at a histopathology reference laboratory using immunohistochemistry to identify cell surface markers. During two years of follow-up, there were two clinical recurrences requiring surgery. To our knowledge, this is the 35th documented case of spindle cell oncocytoma of the pituitary gland and the first that was immunohistochemically negative for epithelial membrane antigen (EMA) and S100; and the first that displayed haematogenous metastasis to the right sphenoparietal sinus. The three surgical procedures were associated with massive intraoperative bleeding and thus resulted in subtotal tumor resection. Following surgery for the recurrences, the patient underwent radiotherapy.

Multifocal and hormone-dependent epithelioid hemangioendothelioma with osteolysis of the second cervical vertebral body: report of an unprecedented surgical approach by using autologous bone graft.

We report the case of a 28-year-old female patient who complained of extreme neck pain when giving birth to a child. Magnetic resonance imaging (MRI) of the cervical spine demonstrated an osteolytic lesion at the second cervical vertebral body (C2). In this presentation, we highlight a transoral surgical approach in order to prevent instability of this osteolytic lesion. To the best of our knowledge, this is the first time that such a route of access has been described for this tumor entity. A histopathologic examination led to the diagnosis of epithelioid hemangioendothelioma. During a follow-up period of 33 months, the patient had no complaints.

In-depth characterization of a long-term, resuscitated model of acute subdural hematoma-induced brain injury.

OBJECTIVE: Acute subdural hematoma (ASDH) is a leading entity in brain injury. Rodent models mostly lack standard intensive care, while large animal models frequently are only short term. Therefore, the authors developed a long-term, resuscitated porcine model of ASDH-induced brain injury and report their findings. METHODS: Anesthetized, mechanically ventilated, and instrumented pigs with human-like coagulation underwent subdural injection of 20 mL of autologous blood and subsequent observation for 54 hours. Continuous bilateral multimodal brain monitoring (intracranial pressure [ICP], cerebral perfusion pressure [CPP], partial pressure of oxygen in brain tissue [PbtO2], and brain temperature) was combined with intermittent neurological assessment (veterinary modified Glasgow Coma Scale [MGCS]), microdialysis, and measurement of plasma protein S100ß, GFAP, neuron-specific enolase [NSE], nitrite+nitrate, and isoprostanes. Fluid resuscitation and continuous intravenous norepinephrine were targeted to maintain CPP at pre-ASDH levels. Immediately postmortem, the brains were taken for macroscopic and histological evaluation, immunohistochemical analysis for nitrotyrosine formation, albumin extravasation, NADPH oxidase 2 (NOX2) and GFAP expression, and quantification of tissue mitochondrial respiration. RESULTS: Nine of 11 pigs survived the complete observation period. While ICP significantly increased after ASDH induction, CPP, PbtO2, and the MGCS score remained unaffected. Blood S100ß levels significantly fell over time, whereas GFAP, NSE, nitrite+nitrate, and isoprostane concentrations were unaltered. Immunohistochemistry showed nitrotyrosine formation, albumin extravasation, NOX2 expression, fibrillary astrogliosis, and microglial activation. CONCLUSIONS: The authors describe a clinically relevant, long-term, resuscitated porcine model of ASDH-induced brain injury. Despite the morphological injury, maintaining CPP and PbtO2 prevented serious neurological dysfunction. This model is suitable for studying therapeutic interventions during hemorrhage-induced acute brain injury with standard brain-targeted intensive care.

Establishing risk-adjusted quality indicators in surgery using administrative data-an example from neurosurgery.

BACKGROUND: The current draft of the German Hospital Structure Law requires remuneration to incorporate quality indicators. For neurosurgery, several quality indicators have been discussed, such as 30-day readmission, reoperation, or mortality rates; the rates of infections; or the length of stay. When comparing neurosurgical departments regarding these indicators, very heterogeneous patient spectrums complicate benchmarking due to the lack of risk adjustment. OBJECTIVE: In this study, we performed an analysis of quality indicators and possible risk adjustment, based only on administrative data. METHODS: All adult patients that were treated as inpatients for a brain or spinal tumour at our neurosurgical department between 2013 and 2017 were assessed for the abovementioned quality indicators. DRG-related data such as relative weight, PCCL (patient clinical complexity level), ICD-10 major diagnosis category, secondary diagnoses, age and sex were obtained. The age-adjusted Charlson Comorbidity Index (CCI) was calculated. Logistic regression analyses were performed in order to correlate quality indicators with administrative data. RESULTS: Overall, 2623 cases were enrolled into the study. Most patients were treated for glioma (n = 1055, 40.2%). The CCI did not correlate with the quality indicators, whereas PCCL showed a positive correlation with 30-day readmission and reoperation, SSI and nosocomial infection rates. CONCLUSION: All previously discussed quality indicators are easily derived from administrative data. Administrative data alone might not be sufficient for adequate risk adjustment as they do not reflect the endogenous risk of the patient and are influenced by certain complications during inpatient stay. Appropriate concepts for risk adjustment should be compiled on the basis of prospectively designed registry studies.

Spine surgery in the International Security Assistance Force Role 3 combat support hospital in Mazar-e-Sharif, northern Afghanistan, 2007-2014.

OBJECTIVESince 2007, a continuous neurosurgery emergency service has been available in the International Security Assistance Force (ISAF) field hospital in Mazar-e-Sharif (MeS), Afghanistan. The object of this study was to assess the number and range of surgical procedures performed on the spine in the period from 2007 to 2014.METHODSThis is a retrospective analysis of the annual neurosurgical caseload statistics from July 2007 to October 2014 (92 months). The distribution of surgical urgency (emergency, delayed urgency, or elective), patient origin (ISAF, Afghan National Army, or civilian population), and underlying causes of diseases and injuries (penetrating injury, blunt injury/fracture, or degenerative disease) was analyzed. The range and pattern of diagnoses in the neurosurgical outpatient department from 2012 and 2013 were also evaluated.RESULTSA total of 341 patients underwent neurosurgical operations in the period from July 2007 to October 2014. One hundred eighty-eight (55.1%) of the 341 procedures were performed on the spine, and the majority of these surgeries were performed for degenerative diseases (127/188; 67.6%). The proportion of spinal fractures and penetrating injuries (61/188; 32.4%) increased over the study period. These spinal trauma diagnoses accounted for 80% of the cases in which patients had to undergo operations within 12 hours of presentation (n = 70 cases). Spinal surgeries were performed as an emergency in 19.8% of cases, whereas 17.3% of surgeries had delayed urgency and 62.9% were elective procedures. Of the 1026 outpatient consultations documented, 82% were related to spinal issues.CONCLUSIONSCompared to the published numbers of cases from neurosurgery units in the rest of the ISAF area, the field hospital in MeS had a considerably lower number of operations. In addition, MeS had the highest rates of both elective neurosurgical operations and Afghan civilian patients. In comparison with the field hospital in MeS, none of the other ISAF field hospitals showed such a strong concentration of degenerative spinal conditions in their surgical spectrum. Nevertheless, the changing pattern of spine-related diagnoses and surgical therapies in the current conflict represents a challenge for future training and material planning in comparable missions.

Primary Amelanotic CNS Melanoma: Case Report and Literature Review.

Primary malignant melanomas of the central nervous system (CNS) are rarely seen entities in the clinical routine. Primary amelanotic melanomas are even rarer. In our literature review, we found only six case reports of primary amelanotic CNS melanomas. Our case report describes the course of a 71-year-old man with a primary amelanotic CNS melanoma with secondary spread to the spine.

[Clinical and Radiological Results after Anterior Cervical Corpectomy with Cage Fusion - a Retrospective Comparison of PEEK vs. Titanium Cages]. / Implantatassoziierte Komplikationen sowie klinischer und radiologischer Verlauf nach anteriorer zervikaler Korpektomie und Cage-Fusion ­ retrospektiver Vergleich von PEEK- gegen Titan-Cages.

Background Anterior cervical corpectomy and fusion (ACCF) has become a standard procedure for patients with spondylotic myelopathy due to multisegmental stenosis of the cervical canal. Beside the fusion technique using autogenous bone grafts, synthetic cages have been increasingly used in recent years. Published information on the clinical and radiological results of different cage materials for ACCF is still limited. The study presented here is the largest series to date reporting clinical and radiological outcomes and complication rates after one- to three-level ACCF using structural polyetheretherketone (PEEK) or titanium cages augmented by anterior plate-screw osteosynthesis. Materials and Methods Retrospective comparative study on 126 patients after cage ACCF using modular PEEK (n = 101) or distractable titanium (n = 25) cages with a minimum follow-up of 6 months. The numbers of hardware failures and implant-related surgical revisions were determined. The rate of subsidence and fusion and the course of lordotic alignment (segmental and regional Cobb's angles) were analysed. Neck Disability Index (NDI) and European Myelopathy Score (EMS) were assessed. Results Significantly greater number of screw and cage complications were detected in the titanium cage group (36 vs. 7.9 % and 64 vs. 36.6 %, respectively). Non-significant trend to a higher rate of implant related revision rate in the titanium cage group (16 vs. 2.97 %). Significantly greater rate of grade I or II fusion in the PEEK cage group after 6 months (82 vs. 52 %). NDI, EMS and lordotic alignment improved significantly in both groups. There were neither significant differences between the two groups nor significant correlations between these clinico-radiological parameters and the cage material. Partial correlations performed with control of parameters showing inhomogenous distribution (patient age, fusion distance, rate of multilevel corpectomy and the rate of intraoperative segmental overdistraction) showed no significant correlations for any of the clinical or radiological outcome parameters and the complications or revisions to the cage material. Conclusion Cages are a safe and effective alternative to autogenous bone graft for ACCF. A significant improvement in clinical and radiological parameters can be achieved with both titanium and PEEK implants. Significant differences between the two cage material groups or significant correlations of clinico-radiological outcome and cage material were not proven. Moreover there is no evidence in the literature for clinical advantages of one special cage material, to date. Therefore further prospective randomised evaluation of different fusion techniques in ACCF is still necessary.

Pediatric Neurosurgical Care in a German Field Hospital in Afghanistan.

Background and Study Objectives Children are commonly found among the injured in war settings. Prognosis often depends on the presence of brain injury. Not all neurosurgery departments of German Armed Forces hospitals, however, have experience in the care of children with neurosurgical conditions. Against this background, we assessed the group of pediatric neurosurgical patients in a German (Role 3) field hospital in Mazar-e-Sharif, Afghanistan. Patients/Materials and Methods We analyzed the operative logbooks from January 1, 2008, to December 31, 2013, to assess the number of neurosurgical procedures that were performed on children (< 18 years of age) at the field hospital of Mazar-e-Sharif. Results During the study period, 327 neurosurgical procedures were performed at the German field hospital. Of these, 29 (9%) were performed on children. The mean age of the pediatric patients (7 girls and 22 boys) was 11.7 years (median age: 12 years; range: 5-17 years). Only three procedures were performed for conditions other than trauma. Pediatric patients accounted for almost 10% of all patients who underwent neurosurgery during a recent military deployment in Mazar-e-Sharif. This percentage is similar to those reported by other nations. These findings show that a considerable number of children underwent neurosurgical treatment. Conclusions Military planners should be aware that Role 3 medical treatment facilities must provide care for pediatric emergencies and must therefore be staffed and equipped accordingly. For military hospitals at home, this means that the management of pediatric patients is an opportunity for medical personnel to receive important pediatric training that enables them to provide care to children in deployed medical facilities.

Survey on Current Postnatal Surgical Management of Myelomeningocele in Germany.

Background and Study Aims Although postnatal surgery can be regarded as the standard of care for open myelomeningocele (MMC), there is no uniform treatment for this condition in Germany. This study assessed the current situation regarding the management of open MMC, a first and essential step toward the development of standards of practice. Patients and Methods In the second half of 2009, we had sent standardized questionnaires to 139 neurosurgery departments and 73 pediatric surgery departments (number of returned questionnaires: 98 and 62, respectively) to identify the principles of MMC management. Newborns with open MMC are treated in 57 of the neurosurgery departments and in 18 of the pediatric surgery departments. Results Overall, 41 of the 57 neurosurgery departments and 16 of the 18 pediatric surgery departments providing care for newborns with MMC perform MMC closure within 24 hours of delivery. In 52 neurosurgery departments and 15 pediatric surgery departments, infants with spina bifida are delivered by planned cesarean section. The diagnostic investigations performed between the time of caesarean delivery and plastic surgical closure vary from none to magnetic resonance imaging of the spine. The criteria underlying the placement of shunts and the time to plastic surgical closure are highly variable. Conclusions The type of treatment that infants with open MMC receive in Germany differs from institution to institution. Clear and consistent guidelines must be established using an interdisciplinary approach to improve treatment and standardize the care provided by surgical specialists for infants with MMC.

Telemetric Intracranial Pressure Measurement: A Graphical Approach to Data Analysis.

PURPOSE: In recent years, radiofrequency identification has been used for the continuous measurement of intracranial pressure (ICP) in patients with a cerebrospinal fluid (CSF) shunt for hydrocephalus . Unlike ICP monitoring in an inpatient setting, measurements in mobile patients outside the hospital provide ICP data that take into account the everyday activities of each individual patient. Common methods of ICP monitoring and analysis cannot be used for those patients. In addition, ICP measurements in mobile patients require considerably longer observation times than in-hospital monitoring. For this reason, ICP measurements over a period of 7 to 10 days must be analyzed effectively and efficiently. METHODS: A possible approach is to analyze ICP data graphically. Pathologic changes can be expected to be associated with specific patterns that can be detected graphically (e.g., Lundberg A waves). Patients without pathologic ICP values and without intracranial pathologies usually show an approximately normal distribution of ICP data. By contrast, patients with pathologic ICP values are likely to show major deviations from a normal distribution such as changes in minimum and maximum values and multimodal distributions. Against this background, we present a new graphical method for detecting pathologic conditions. This novel method is based on the distribution of ICP data that is assessed using GNU R, a free software package for statistical computing and graphics. RESULTS: A left-skewed distribution indicates CSF shunt overdrainage and a right-skewed distribution suggests CSF shunt underdrainage. In addition, an additive analysis of the number of physiologic ICP values can be helpful in detecting possible causes of CSF shunt overdrainage or underdrainage. The approach presented here shows that patients with hydrocephalus objectively benefited from ICP-guided adjustments of the opening pressure of a shunt valve or the insertion of a valve. This objective improvement was confirmed by the patients' subjective perception of well-being. CONCLUSIONS: Further investigations should be performed to examine the influence of multimodal ICP distributions and to assess how data analysis is affected by a drift that can occur when a sensor has been in place for an extended period of time.

Establishment of the Military Neurosurgeons Committee within the World Federation of Neurosurgical Societies.

In 2009, during the World Congress of Neurological Surgery in Boston, Massachusetts, the World Federation of Neurosurgical Societies (WFNS) Executive Committee decided to establish a Military Neurosurgeons Committee. A separate scientific session on military neurosurgery was held at the next WFNS Interim Meeting in September 2011 in Brazil. A further separate session on military neurosurgery will take place at the next WFNS Meeting in Seoul, South Korea.

Evaluation of platelet-rich plasma and hydrostatic pressure regarding cell differentiation in nucleus pulposus tissue engineering.

Generation of a biological nucleus pulposus (NP) replacement by tissue engineering appears to be a promising approach for the therapy of early stages of intervertebral disc degeneration. Thereby, autologous mesenchymal stem cells (MSCs) represent an attractive cell source compared to cells of the NP that are already altered in their phenotype due to degenerative processes. This study compares the influence of 3D pellet culture and alginate beads, as well as that of different media compositions, by the addition of human platelet-rich plasma (PRP) or transforming growth factor (TGF-ß1 ) in interaction with hydrostatic pressure on chondrogenic differentiation of human MSCs compared to NP cells. We found that gene expression of the chondrogenic markers aggrecan, collagen type 2 and collagen type 1 and Sox9 was considerably lower in cells cultivated with PRP compared to TGF-ß1 . Immunohistology confirmed this result at protein level in pellet culture. Additionally, the pellet culture system was found to be more suitable than alginate beads. A positive influence of hydrostatic pressure could only be shown for individual donors. In summary, in comparison to TGF-ß1 , human PRP did not induce adequate chondrogenic differentiation for both culture systems and cell types used. The mixture of growth factors in PRP promoted proliferation rather than chondrogenic differentiation. Based on these results, an application of PRP in human NP tissue-engineering approaches cannot be recommended.

A survey on current practice in the neurosurgical management of preterm infants with posthemorrhagic hydrocephalus in Germany.

BACKGROUND AND STUDY AIMS: Different approaches to the management of preterm infants with posthemorrhagic hydrocephalus (PHH) are described in the literature. Likewise, neurosurgical and pediatric surgical departments in German hospitals use different methods to treat these patients. The aim of this study was therefore to assess the current situation regarding the management of PHH, which is a first and essential step toward the development of standards of practice. PATIENTS AND METHODS: In the second half of 2009, we sent standardized questionnaires to 139 neurosurgical departments (number of returned questionnaires: 98) and 73 pediatric surgical departments (returned questionnaires: 62) to identify the principles of PHH management. Preterm infants with PHH are treated in 61 of the neurosurgical and in 20 of the pediatric surgical departments. RESULTS: 43 of the 61 neurosurgical departments and 17 of the 20 pediatric surgical departments providing care for preterm infants with PHH treat less than 10 preterm infants with PHH per year. Reservoir placement is performed as the initial treatment in 48 neurosurgical and in 14 pediatric surgical departments.The criteria for the placement of ventriculoperitoneal shunts and the implantation procedure itself are highly variable. Moreover, the percentage of children who require a CSF shunt after initial treatment for PHH ranges between 5 and 95%. CONCLUSIONS: In Germany, the type of treatment of infants with PHH differs from institution to institution. Clear and consistent guidelines must be established in an interdisciplinary approach to improve and better coordinate the management of infants with PPH.

Intraoperative image guidance in neurosurgery: development, current indications, and future trends.

Introduction. As minimally invasive surgery becomes the standard of care in neurosurgery, it is imperative that surgeons become skilled in the use of image-guided techniques. The development of image-guided neurosurgery represents a substantial improvement in the microsurgical treatment of tumors, vascular malformations, and other intracranial lesions. Objective. There have been numerous advances in neurosurgery which have aided the neurosurgeon to achieve accurate removal of pathological tissue with minimal disruption of surrounding healthy neuronal matter including the development of microsurgical, endoscopic, and endovascular techniques. Neuronavigation systems and intraoperative imaging should improve success in cranial neurosurgery. Additional functional imaging modalities such as PET, SPECT, DTI (for fiber tracking), and fMRI can now be used in order to reduce neurological deficits resulting from surgery; however the positive long-term effect remains questionable for many indications. Method. PubMed database search using the search term "image guided neurosurgery." More than 1400 articles were published during the last 25 years. The abstracts were scanned for prospective comparative trials. Results and Conclusion. 14 comparative trials are published. To date significant data amount show advantages in intraoperative accuracy influencing the perioperative morbidity and long-term outcome only for cerebral glioma surgery.

Three years of neurosurgical experience in a multinational field hospital in northern Afghanistan.

BACKGROUND: Since July 2007, neurosurgical services have been continuously available in a multinational Role 3 field hospital in Mazar-e-Sharif (MeS), Afghanistan. In this paper, we analyse a 3-year neurosurgical caseload experience. METHODS: We retrospectively analysed the neurosurgical caseload at a Role 3 medical treatment facility in northern Afghanistan between October 2007 and October 2010. The cases were divided into acute, urgent and elective procedures and into cranial, spinal, peripheral nerve and miscellaneous surgeries. RESULTS: A total of 190 surgeries were performed. Of these, 50 operations (26.3%) were acute procedures that were conducted to save lives or preserve neurological function. In addition, operations included 47 urgent (24.7%) and 93 elective (49%) procedures. There were 58 cranial surgeries (30.5%), 113 spinal surgeries (59.5%), 11 peripheral nerve surgeries (5.8%), and 8 miscellaneous surgeries (4.2%). Surgical treatment was provided to 13 International Security Assistance Force (ISAF) soldiers (6.8%), 22 members of the Afghan National Security Forces (11.6%), and 155 Afghan civilians (81.6%). CONCLUSIONS: The primary mission of the field hospital is to provide sick, injured or wounded ISAF personnel with medical and surgical care, the outcome of which must correspond to standards prevailing in Germany. Only a very small number of neurosurgical operations performed in MeS met the criteria established by this mission statement and by the modern principles of damage-control wartime surgery. This is completely different from the experience reported by other ISAF nations in eastern and southern Afghanistan.

Intraoperative three-dimensional imaging in selective decompression for lumbar spinal stenosis: a useful tool in theory but also in everyday practice?

Background. We conducted a pilot study to investigate the value of an Iso-C3D imaging system in determining the extent of decompression of lumbar spinal stenosis during surgery. We now address the question whether this imaging has become a routine tool. Material and Methods. Ten patients who underwent unilateral decompression for lumbar spinal stenosis were intraoperatively examined using the Iso-C3D imaging system. Four years after this study, we investigated whether this intraoperative imaging modality is still being used. Results. Evaluable images were intraoperatively obtained for all patients. In two cases, the surgical procedure was changed on the basis of the images. Myelography did not provide any additional information. In the four years following the study, this intraoperative imaging technique has not been used again. Conclusion. Intraoperative imaging using the Iso-C3D system provides additional safety. It, however, has not become established as a routine procedure.