The evolution and integration of technology in spinal neurosurgery: A scoping review.

Spinal disorders pose a significant global health challenge, affecting nearly 5% of the population and incurring substantial socioeconomic costs. Over time, spinal neurosurgery has evolved from basic 19th-century techniques to today's minimally invasive procedures. The recent integration of technologies such as robotic assistance and advanced imaging has not only improved precision but also reshaped treatment paradigms. This review explores key innovations in imaging, biomaterials, and emerging fields such as AI, examining how they address long-standing challenges in spinal care, including enhancing surgical accuracy and promoting tissue regeneration. Are we at the threshold of a new era in healthcare technology, or are these innovations merely enhancements that may not fundamentally advance clinical care? We aim to answer this question by offering a concise introduction to each technology and discussing in depth its status and challenges, providing readers with a clearer understanding of its actual potential to revolutionize surgical practices.

Healthcare transition in pediatric neurosurgery: lessons learned from a pilot program for patients with hydrocephalus and spina bifida.

OBJECTIVE: The pediatric neurosurgical community has increasingly recognized the importance of healthcare transition, the process of moving a patient from a pediatric to an adult model of care. However, surveys of pediatric neurosurgeons have revealed that few institutions have formal transition programs. Here, the authors share their preliminary experience with the development of a formal transition pilot program for patients with spina bifida and/or hydrocephalus. METHODS: Patients 18 years of age or older with a diagnosis of spina bifida and/or hydrocephalus who were followed by a pediatric neurosurgeon at Connecticut Children's from January 2017 to December 2023 and were recommended to transition to an adult neurosurgeon were retrospectively reviewed. Patients in the informal transition program (ITP) cohort (i.e., the recommendation to transition was made before the formal transition program [FTP] was developed in early 2020) were compared with those in the FTP cohort. RESULTS: Twenty-two patients met inclusion criteria with 7 (31.8%) in the ITP cohort and 15 (68.2%) in the FTP cohort. The median age at the time of the recommendation to transition was similar in both ITP and FTP cohorts (24 [IQR 20-35] years vs 25 [IQR 24-27] years, respectively). Four (57.1%) patients in the ITP cohort had a confirmed visit with an adult neurosurgeon, compared with 13 (86.7%) patients in the FTP cohort (p = 0.274). One patient in the ITP cohort with a failed transition returned to pediatric neurosurgical care, and 1 patient in the FTP cohort required a shunt revision by an adult neurosurgeon within 1 year of the recommendation to transition. CONCLUSIONS: Healthcare transition is recognized as a priority within pediatric neurosurgery, but structured, formal transition programs remain underdeveloped. The authors' preliminary experience with a pilot transition program demonstrated that patients who underwent a formal transition were more likely to successfully establish care with an adult neurosurgeon and trended toward less resource utilization.

Artificial intelligence innovations in neurosurgical oncology: a narrative review.

PURPOSE: Artificial Intelligence (AI) has become increasingly integrated clinically within neurosurgical oncology. This report reviews the cutting-edge technologies impacting tumor treatment and outcomes. METHODS: A rigorous literature search was performed with the aid of a research librarian to identify key articles referencing AI and related topics (machine learning (ML), computer vision (CV), augmented reality (AR), virtual reality (VR), etc.) for neurosurgical care of brain or spinal tumors. RESULTS: Treatment of central nervous system (CNS) tumors is being improved through advances across AI-such as AL, CV, and AR/VR. AI aided diagnostic and prognostication tools can influence pre-operative patient experience, while automated tumor segmentation and total resection predictions aid surgical planning. Novel intra-operative tools can rapidly provide histopathologic tumor classification to streamline treatment strategies. Post-operative video analysis, paired with rich surgical simulations, can enhance training feedback and regimens. CONCLUSION: While limited generalizability, bias, and patient data security are current concerns, the advent of federated learning, along with growing data consortiums, provides an avenue for increasingly safe, powerful, and effective AI platforms in the future.

Current Applications of VR/AR (Virtual Reality/Augmented Reality) in Pediatric Neurosurgery.

Neurosurgical procedures are some of the most complex procedures in medicine and since the advent of the field, planning, performing, and learning them has challenged the neurosurgeon. Virtual reality (VR) and augmented reality (AR) are making these challenges more manageable. VR refers to a virtual digital environment that can be experienced usually through use of stereoscopic glasses and controllers. AR, on the other hand, fuses the natural environment with virtual images, such as superimposing a preoperative MRI image on to the surgical field [1]. They initially were used primarily as neuronavigational tools but soon their potential in other areas of surgery, such as planning, education, and assessment, was noted and explored. Through this chapter, we outline the history and evolution of these two technologies over the past few decades, describe the current state of the technology and its uses, and postulate future directions for research and implementation.

"The novel dura substitute: a revolutionary advancement in neurosurgery".

This Article provides a concise summary of the comprehensive exploration into the dura mater, dural tears, and the groundbreaking medical device, ArtiFascia® Dura Substitute. The neuroanatomy of the dura mater is elucidated, emphasizing its resilience and susceptibility to tears during spinal surgery. Dural repair methods are scrutinized, with research findings revealing the efficacy of primary closure with or without a patch.The introduction of ArtiFascia®, a nanofiber-based resorbable dural repair graft, represents a pivotal moment in neurosurgery. Obtaining 510(k) clearance from the FDA, ArtiFascia® demonstrates exceptional biological benefits, including enhanced cellular adhesion and tissue regeneration. The device's safety is affirmed through chemical analysis and toxicological risk assessment.The NEOART study, a randomized clinical trial involving 85 subjects across prominent European medical centers, validates ArtiFascia®'s superiority over existing dural substitutes. Noteworthy findings include exceptional graft strength, durability, and its ability to withstand physiological pressures.In conclusion, ArtiFascia® marks a revolutionary era in neurosurgery, promising safer and more effective solutions. This innovative device has the potential to elevate standards of care, offering both patients and surgeons an improved experience in navigating the complexities of neurosurgical procedures. The abstract encapsulates the key elements of the research, emphasizing the transformative impact of ArtiFascia® in the field.

Evaluation of the safety, accuracy, and helpfulness of the GPT-4.0 Large Language Model in neurosurgery.

BACKGROUND: Although prior work demonstrated the surprising accuracy of Large Language Models (LLMs) on neurosurgery board-style questions, their use in day-to-day clinical situations warrants further investigation. This study assessed GPT-4.0's responses to common clinical questions across various subspecialties of neurosurgery. METHODS: A panel of attending neurosurgeons formulated 35 general neurosurgical questions spanning neuro-oncology, spine, vascular, functional, pediatrics, and trauma. All questions were input into GPT-4.0 with a prespecified, standard prompt. Responses were evaluated by two attending neurosurgeons, each on a standardized scale for accuracy, safety, and helpfulness. Citations were indexed and evaluated against identifiable database references. RESULTS: GPT-4.0 responses were consistent with current medical guidelines and accounted for recent advances in the field 92.8 % and 78.6 % of the time respectively. Neurosurgeons reported GPT-4.0 responses providing unrealistic information or potentially risky information 14.3 % and 7.1 % of the time respectively. Assessed on 5-point scales, responses suggested that GPT-4.0 was clinically useful (4.0 ± 0.6), relevant (4.7 ± 0.3), and coherent (4.9 ± 0.2). The depth of clinical responses varied (3.7 ± 0.6), and "red flag" symptoms were missed 7.1 % of the time. Moreover, GPT-4.0 cited 86 references (2.46 citations per answer), of which only 50 % were deemed valid, and 77.1 % of responses contained at least one inappropriate citation. CONCLUSION: Current general LLM technology can offer generally accurate, safe, and helpful neurosurgical information, but may not fully evaluate medical literature or recent field advances. Citation generation and usage remains unreliable. As this technology becomes more ubiquitous, clinicians will need to exercise caution when dealing with it in practice.

Intraoperative MRI: A Review of Applications Across Neurosurgical Specialties.

Intraoperative MRI (iMRI) made its debut to great fanfare in the mid-1990s. However, the enthusiasm for this technology with seemingly obvious benefits for neurosurgeons has waned. We review the benefits and utility of iMRI across the field of neurosurgery and present an overview of the evidence for iMRI for multiple neurosurgical disciplines: tumor, skull base, vascular, pediatric, functional, and spine. Publications on iMRI have steadily increased since 1996, plateauing with approximately 52 publications per year since 2011. Tumor surgery, especially glioma surgery, has the most evidence for the use of iMRI contributing more than 50% of all iMRI publications, with increased rates of gross total resection in both adults and children, providing a potential survival benefit. Across multiple neurosurgical disciplines, the ability to use a multitude of unique sequences (diffusion tract imaging, diffusion-weighted imaging, magnetic resonance angiography, blood oxygenation level-dependent) allows for specialization of imaging for various types of surgery. Generally, iMRI allows for consideration of anatomic changes and real-time feedback on surgical outcomes such as extent of resection and instrument (screw, lead, electrode) placement. However, implementation of iMRI is limited by cost and feasibility, including the need for installation, shielding, and compatible tools. Evidence for iMRI use varies greatly by specialty, with the most evidence for tumor, vascular, and pediatric neurosurgery. The benefits of real-time anatomic imaging, a lack of radiation, and evaluation of surgical outcomes are limited by the cost and difficulty of iMRI integration. Nonetheless, the ability to ensure patients are provided by a maximal yet safe treatment that specifically accounts for their own anatomy and highlights why iMRI is a valuable and underutilized tool across multiple neurosurgical subspecialties.

hglobal-Index: A Novel Author-Level Measure of the Diffusion of Scientific Ideas Among High-, Low-, and Middle-Income Countries.

OBJECTIVE: To describe an intuitive and useful method for measuring the global impact of a medical scholar's research ideas by examining cross-border citations (CBCs) of peer-reviewed neurosurgical publications. METHODS: Publication and citation data for a random sample of the top 50 most academically productive neurosurgeons were obtained from Scopus Application Programming Interface. We characterized an author-level global impact index analogous to the widely used h-index, the hglobal-index, defined as the number of published peer-reviewed manuscripts with at least the same number of CBCs. To uncover socioeconomic insights, we explored the hglobal-index for high-, middle-, and low-income countries. RESULTS: The median (interquartile range) number of publications and CBCs were 144 (62-255) and 2704 (959-5325), respectively. The median (interquartile range) h-index and hglobal-index were 42 (23-61) and 32 (17-38), respectively. Compared with neurosurgeons in the random sample, the 3 global neurosurgeons had the highest hglobal-indices in low-income countries at 17, 13, and 9, despite below-average h-index scores of 33, 38, and 19, respectively. CONCLUSION: This intuitive update to the h-index uses CBCs to measure the global impact of scientific research. The hglobal-index may provide insight into global diffusion of medical ideas, which can be used for social science research, author self-assessment, and academic promotion.

Comparing Outcomes for Emergent Cranial Neurosurgical Procedures Performed "During Hours" and "After Hours".

OBJECTIVE: Surgery performed at night and on weekends is thought to be associated with increased complications. However, the impact of time of day on outcomes has not been studied within cranial neurosurgery. We aim to determine if there are differences in outcomes for cranial neurosurgery performed after hours (AH) compared with during hours (DH). METHODS: We performed a single-center retrospective study of cranial neurosurgery patients who underwent emergent surgery from January 2015 through December 2019. Surgery was considered DH if the incision occurred between 8 am and 5 pm Monday through Friday. We assessed outcome measures for differences between operations performed DH or AH. RESULTS: Three-hundred and ninety-three patients (114 DH, 279 AH) underwent surgery. There was a lower rate of return to the operating room within 30 days for AH (8.6%) compared with DH (14.0%), P = 0.03, on multivariate analysis. There were no significant differences in length of operation, estimated blood loss, improvement in Glasgow Coma Scale, intensive care unit and total hospital length of stay, 30-day readmission, 30-day mortality, and in-hospital mortality for cases performed DH compared with AH. Further subgroup analyses were performed for patients who underwent immediate surgery for subdural hematomas, with no differences noted in outcomes on multivariate analysis. CONCLUSIONS: This study suggests that operating AH does not appear to negatively impact outcomes when compared with operating DH, in cases of cranial neurosurgical emergencies. Further study assessing the impact on elective neurosurgical cases is required.

Global Neurosurgery Advances From Trenches to Bedside: Lessons From Neurosurgical Care in War, Humanitarian Assistance, and Disaster Response.

INTRODUCTION: War has influenced the evolution of global neurosurgery throughout the past century. Armed conflict and mass casualty disasters (MCDs), including Humanitarian Assistance Disaster Relief missions, require military surgeons to innovate to meet extreme demands. However, the military medical apparatus is seldom integrated into the civilian health care sector. Neurosurgeons serving in the military have provided a pragmatic template for global neurosurgeons to emulate in humanitarian disaster responses. In this paper, we explore how wars and MCD have influenced innovations of growing interest in the resource-limited settings of global neurosurgery. METHODS: We performed a narrative review of the literature examining the influence of wars and MCD on contemporary global neurosurgery practices. RESULTS: Wartime innovations that influenced global neurosurgery include the development of triage systems and modernization with airlifts, the implementation of ambulance corps, early operation on cranial injuries in hospital camps near the battlefield, the use of combat body armor, and the rise of damage control neurosurgery. In addition to promoting task-shifting and task-sharing, workforce shortages during wars and disasters contributed to the establishment of the physician assistant/physician associate profession in the USA. Low- and middle-income countries (LMICs) face similar challenges in developing trauma systems and obtaining advanced technology, including neurosurgical equipment like battery-powered computed tomography scanners. These challenges-ubiquitous in low-resource settings-have underpinned innovations in triage and wound care, rapid evacuation to tertiary care centers, and minimizing infection risk. CONCLUSION: War and MCDs have catalyzed significant advancements in neurosurgical care both in the pre-hospital and inpatient settings. Most of these innovations originated in the military and subsequently spread to the civilian sector as military neurosurgeons and reservist civilian neurosurgeons returned from the battlefront or other low-resource locations. Military neurosurgeons have utilized their experience in low-resource settings to make volunteer global neurosurgery efforts in LMICs successful. LMICs have, by necessity, responded to challenges arising from resource shortages by developing innovative, context-specific care paradigms and technologies.

A systematic review of the power of standardization in pediatric neurosurgery.

In the current neurosurgical field, there is a constant emphasis on providing the best care with the most value. Such work requires the constant optimization of not only surgical but also perioperative services. Recent work has demonstrated the power of standardized techniques in limiting complication while promoting optimal outcomes. In this review article, protocols addressing operative and perioperative care for common pediatric neurosurgical procedures are discussed. These articles address how various institutions have optimized procedures through standardization. Our objective is to improve patient outcomes through the optimization of protocols.

Augmented Reality in Neurosurgery: A New Paradigm for Training.

Augmented reality (AR) involves the overlay of computer-generated images onto the user's real-world visual field to modify or enhance the user's visual experience. With respect to neurosurgery, AR integrates preoperative and intraoperative imaging data to create an enriched surgical experience that has been shown to improve surgical planning, refine neuronavigation, and reduce operation time. In addition, AR has the potential to serve as a valuable training tool for neurosurgeons in a way that minimizes patient risk while facilitating comprehensive training opportunities. The increased use of AR in neurosurgery over the past decade has led to innovative research endeavors aiming to develop novel, more efficient AR systems while also improving and refining present ones. In this review, we provide a concise overview of AR, detail current and emerging uses of AR in neurosurgery and neurosurgical training, discuss the limitations of AR, and provide future research directions. Following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), 386 articles were initially identified. Two independent reviewers (GH and AC) assessed article eligibility for inclusion, and 31 articles are included in this review. The literature search included original (retrospective and prospective) articles and case reports published in English between 2013 and 2023. AR assistance has shown promise within neuro-oncology, spinal neurosurgery, neurovascular surgery, skull-base surgery, and pediatric neurosurgery. Intraoperative use of AR was found to primarily assist with surgical planning and neuronavigation. Similarly, AR assistance for neurosurgical training focused primarily on surgical planning and neuronavigation. However, studies included in this review utilize small sample sizes and remain largely in the preliminary phase. Thus, future research must be conducted to further refine AR systems before widespread intraoperative and educational use.

Application of Glasses-Free Augmented Reality Localization in Neurosurgery.

OBJECTIVE: The accurate localization of intracranial lesions is critical in neurosurgery. Most surgeons locate the vast majority of neurosurgical sites through skull surface markers, combined with neuroimaging examination and marking lines. This project's primary purpose was to develop an augmented reality (AR) technology or tool that can be used for surgical positioning using the naked eye. METHODS: Brain models were predesigned with intracranial lesions using computerized tomography scan, and Digital Imaging and Communications in Medicine data were segmented and modeled by 3D slicer software. The processed data were imported into a smartphone 3D viewing software application (Persp 3D) and were used by a Remebot surgical robot. The localization of intracranial lesions was performed, and the AR localization error was calculated compared with standard robot localization. RESULTS: After mastering the AR localization registration method, surgeons achieved an average localization error of 1.39 ± 0.82 mm. CONCLUSIONS: The error of AR positioning technology in surgical simulation tests based on brain modeling was millimeter level, which has verified the feasibility of clinical application. More efficient registration remains a need that should be addressed.

Topic Reviews in Neurosurgical Journals: An Analysis of Publication Trends.

BACKGROUND: Topic review articles have become increasingly popular, even as the neurosurgical community looks to peer-reviewed journals as a source of discovery in basic and clinical science. In this study we quantify the prevalence of topic review articles in top neurosurgery journals. METHODS: The top 20 neurosurgery journals were defined by Google Scholar metrics. The PubMed database quantified the number of topic reviews compared with the total number of articles published; data were analyzed for trends between 1945 and 2022. RESULTS: All 20 journals have published topic reviews since the start of records on PubMed. Total publications have increased from <500 before 1980 to >8000 in 2022. Topic reviews have increased from <1% before 1980, to 2% by 2000, and to 3%-4% since 2010. The linear trend line equation for the total percentage of reviews in all journals shows a small increase in topic reviews per year. Three journals decreased review publication whereas 4 have reached prevalence >10%. The prevalence of topic reviews increased significantly from the first (2.13) to the last (4.76) year of publication (P = 0.003). CONCLUSIONS: The increasing prevalence of topic reviews is seen in most neurosurgery journals, reflecting supply and demand. Although there are benefits to these articles, they do not contribute novel data. Actions such as defining and labeling this publication type in journals and databases will improve the transparency of research methods. Academic neurosurgeons should further expand their knowledge and not become focused only on introspection into and review of neurosurgical understanding and practice.

Technical evolution of pediatric neurosurgery: the evolution of intraoperative imaging.

Imaging has always been fundamental to neurosurgery, and its evolution over the last century has made a dramatic transformation in the ability of neurosurgeons to define pathology and preserve normal tissue during their operations. In the mid-70 s, the development of computerized cross-sectional imaging with CT scan and subsequently MRI have revolutionized the practice of neurosurgery. Later, further advances in computer technology and medical engineering have allowed the combination of many modalities to bring them into the operating theater. This evolution has allowed real-time intraoperative imaging, in the hope of helping neurosurgeons achieve accuracy, maximal safe resection, and the implementation of minimally invasive techniques in brain and spine pathologies. Augmented reality and robotic technologies are also being applied as useful intra-operative techniques that will improve surgical planning and outcomes in the future. In this article, we will review imaging modalities and provide our institutional perspective on how we have integrated them into our practice.

From white to blue light: evolution of endoscope-assisted intracranial tumor neurosurgery and expansion to intraaxial tumors.

OBJECTIVE: Intraoperative use of the endoscope to assist in visualization of intracranial tumor pathology has expanded with increasing surgeon experience and improved instrumentation. The authors aimed to study how advancements in endoscopic technology have affected the evolution of endoscope use, with particular focus on blue light-filter modification allowing for discrimination of fluorescent tumor tissue following 5-ALA administration. METHODS: A retrospective analysis of patients undergoing craniotomy for tumor resection at a single institution between February 2012 and July 2021 was performed. Patients were included if the endoscope was used for diagnostic tumor cavity inspection or therapeutic assistance with tumor resection following standard craniotomy and microsurgical tumor resection, with emphasis on those cases in which blue light endoscopy was used. Medical records were queried for patient demographics, operative reports describing the use of the endoscope and extent of resection, associations with tumor pathology, and postoperative outcomes. Preoperative and postoperative MR images were reviewed for radiographic extent of resection. RESULTS: A total of 52 patients who underwent endoscope-assisted craniotomy for tumor were included. Thirty patients (57.7%) were men and the average age was 52.6 ± 16.1 years. Standard white light endoscopes were used for assistance with tumor resection in 28 cases (53.8%) for tumors primarily located in the ventricular system, parasellar region, and cerebellopontine angle. A blue light endoscope for detection of 5-ALA fluorescence was introduced into our practice in 2014 and subsequently used for assistance with tumor resection in 24 cases (46.2%) (intraaxial: n = 22, extraaxial: n = 2). Beyond the use of the surgical microscope as the primary visualization source, the blue light endoscope was used to directly perform additional tumor resection in 19/21 cases as a result of improved fluorescence detection as compared to the surgical microscope. No complications were associated with the use of the endoscope or with additional resection performed under white or blue light visualization. CONCLUSIONS: Endoscopic assistance to visualize intracranial tumors had previously been limited to white light, assisting mostly in the visualization of extraaxial tumors confined to intraventricular and cisternal compartments. Blue light-equipped endoscopes provide improved versatility and visualization of 5-ALA fluorescing tissue beyond the capability of the surgical microscope, thereby expanding its use into the realm of intraaxial tumor resections.