Nontechnical Skills in Neurosurgery: A Systematic Review of the Literature.

BACKGROUND: Undesirable events in the neurosurgery operating theater have less often been the result of a technical error than of a dysfunction linked to nontechnical skills (NTSs). The essential aim of our study was to perform a systematic review of the reported data on NTS in neurosurgery. Our secondary objective was to identify the NTSs more specific to neurosurgery to define the training needs of neurosurgery trainees. METHODS: The MEDLINE and Cochrane Database of Systematic Reviews were searched according to the PRISMA (preferred reporting items for systematic reviews and meta-analysis) guidelines. The search initially identified 2132 reports, of which 21 were eligible for systematic study. Data were extracted from the report regarding study design, sample size, NTSs assessed, and assessment tools, and the key results were collected. RESULTS: Interpersonal skills (communication, teamwork), cognitive skills (decision making, situational awareness), and personal resource factors (coping with stress or fatigue) were specifically identified. No study had used assessment tools such as NOTECHS (nontechnical skills), NOTSS (nontechnical skills for surgeons), or OTAS (observational teamwork assessment for surgery). They were performed in a real environment in 11 cases, in a simulated environment in 9, and during theoretical teaching in 1 case. CONCLUSIONS: Very few studies have been performed concerning neurosurgical NTSs, despite the increasing the number of studies during the past few years on NTSs in other domains of surgery. Society has been concentrating more and more on the quality and safety of medical care. The development and application of NTS assessment tools is, therefore, essential to provide assistance in the training of future neurosurgeons.

Spinal Dural Arteriovenous Fistulas: Clinical Outcome After Surgery Versus Embolization: A Retrospective Study.

OBJECTIVE: Spinal dural arteriovenous fistulas (SDAVFs) are rare vascular spinal malformations. According to the reported data, surgery seems to result in better occlusion rates than endovascular treatment. However, the post-treatment evolution of neurological symptoms stratified by the treatment remains unknown. The main objective of the present study was to compare the clinical outcomes for patients according to the treatment method. METHODS: The data from 63 patients with SDAVFs from 2000 to 2017 at 4 academic neurosurgical departments were retrospectively analyzed. Preoperative and postoperative examination neurological status was assessed using the Aminoff-Logue scale (ALS), which evaluates gait and micturition disturbances. Initial occlusion, late recurrence, and complications of the 2 techniques were also reviewed. RESULTS: Patients who had undergone surgery and embolization improved clinically on the ALS (P = 0.0009), and no significant differences were found between the 2 techniques. Subgroup analysis using the ALS showed that patients who had undergone surgery and embolization without late recurrence improved (P < 0.0001 and P = 0.0334, respectively) and that patients who had undergone surgery or embolization with late recurrence did not improve. The initial occlusion rate was in favor of surgery, with 91.3% versus 70% for endovascular treatment (P = 0.050). The late recurrence rate was higher for embolization (21.4% vs. 9.1% for surgery; P = 0.28). CONCLUSIONS: Surgery can be proposed as first-line treatment of SDAVFs after multidisciplinary discussion between neurosurgeons and neuroradiologists. The development of late recurrence negatively affects the neurological outcome of patients.

Relationships Between Expertise, Crew Familiarity and Surgical Workflow Disruptions: An Observational Study.

BACKGROUND: Teamwork is an essential factor in reducing workflow disruption (WD) in the operating room. Team familiarity (TF) has been recognized as an antecedent to surgical quality and safety. To date, no study has examined the link between team members' role and expertise, TF and WD in surgical setting. This study aimed to examine the relationships between expertise, surgeon-scrub nurse familiarity and WD. METHODS: We observed a convenience sample of 12 elective neurosurgical procedures carried out by 4 surgeons and 11 SN with different levels of expertise and different degrees of familiarity between surgeons and SN. We calculated the number of WD per unit of coding time to control for the duration of operation. We explored the type and frequency of WD, and the differences between the surgeons and SN. We examined the relationships between duration of WD, staff expertise and surgeon-scrub nurse familiarity. RESULTS: 9.91% of the coded surgical time concerned WD. The most frequent causes of WD were distractions (29.7%) and colleagues' interruptions (25.2%). This proportion was seen for SN, whereas teaching moments and colleagues' interruptions were the most frequent WD for surgeons. The WD was less high among expert surgeons and less frequent when surgeon was familiar with SN. CONCLUSIONS: The frequency of WD during surgical time can compromise surgical quality and patient safety. WD seems to decrease in teams with high levels of surgeon-scrub nurse familiarity and with development of surgical expertise. Favoring TF and giving feedback to the team about WD issues could be interesting ways to improve teamwork.

Modern Management of Meningiomas Compressing the Optic Nerve: A Systematic Review.

OBJECTIVE: Meningiomas that compress the optic nerve (ON) can lead to different visual outcomes depending on the segment of ON affected (intraorbital, canalicular, and intracranial). In this study, we performed a comprehensive comparison of the management options (surgery, radiation, or observation alone) for meningiomas compressing the ON, categorized by location and relation to the ON. METHODS: MEDLINE, EMBASE, Web of Science, and the Cochrane Database of Systematic reviews databases were searched according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Data were extracted from the articles regarding anatomic location, initial visual impairment, surgical procedure, visual outcome, morbidity and mortality, gross total removal, and requirement for postoperative radiotherapy. RESULTS: Of the 47 articles eligible for full-text reading, 9 surgical studies met our inclusion criteria. Data from 317 patient cases were extracted. In patients in whom the intracranial segment of the ON was impaired in isolation, 49% experienced visual improvement after surgery. When the meningioma affected the canalicular segment or intraorbital segment, visual improvement after surgery was 31% and 11%, respectively. Of patients who underwent surgery for the intraorbital segment of the ON, 56% experienced a decline in visual outcome. CONCLUSIONS: When a neurosurgeon deals with a meningioma compressing the ON, opening the optic canal is suggested if invasion is suspected on the preoperative imaging. Extra caution should be used when operating on meningiomas with ON sheath adhesion, given the higher evidence of postoperative visual worsening.

Fluorescein-guided resection of brain arteriovenous malformations: A short series.

Brain arteriovenous malformations (AVM) are complex and highly challenging lesions, for which intra-operative indocyanin green fluorescence video angiography is widely used. Fluorescein video angiography (FVA) recently appeared as an alternative technique but the feasibility and usefulness of this technique is yet uncertain. This short series reports our preliminary experience of FVA in intracranial AVM surgery. We retrospectively studied the cases of seven patients who had FVA for an AVM surgery. The primary objective of this study was to assess the utility of FVA as judged by the surgeon. Secondary objectives were the evaluation of the tolerance of bolus injection of fluorescein in the context of cranial surgery, the comparison with ICG and the rate of complete removal. For each of the seven patients, FVA was performed after exposure of the AVM and before the resection; it was visualized directly through the eyepieces of the microscope and helped in the identification of arterial feeders and draining veins. In one case, post-resection FVA allowed the visualization of a residual shunt and the resection was completed. In two cases, ICG and FVA brought comparable information. The resection was complete in all cases, confirmed by post-operative imaging. There was no anaphylactic complication. This preliminary work suggests that FVA is a simple and well tolerated technique, comparable to ICG angiography. Prospective and larger studies are needed to confirm the clinical benefit of this tool.

Surgical skills: Can learning curves be computed from recordings of surgical activities?

PURPOSE: Surgery is one of the riskiest and most important medical acts that are performed today. The need to improve patient outcomes and surgeon training, and to reduce the costs of surgery, has motivated the equipment of operating rooms with sensors that record surgical interventions. The richness and complexity of the data that are collected call for new methods to support computer-assisted surgery. The aim of this paper is to support the monitoring of junior surgeons learning their surgical skill sets. METHODS: Our method is fully automatic and takes as input a series of surgical interventions each represented by a low-level recording of all activities performed by the surgeon during the intervention (e.g., cut the skin with a scalpel). Our method produces a curve describing the process of standardization of the behavior of junior surgeons. Given the fact that junior surgeons receive constant feedback from senior surgeons during surgery, these curves can be directly interpreted as learning curves. RESULTS: Our method is assessed using the behavior of a junior surgeon in anterior cervical discectomy and fusion surgery over his first three years after residency. They revealed the ability of the method to accurately represent the surgical skill evolution. We also showed that the learning curves can be computed by phases allowing a finer evaluation of the skill progression. CONCLUSION: Preliminary results suggest that our approach constitutes a useful addition to surgical training monitoring.

Spheno-Orbital Meningiomas Surgery: Multicenter Management Study for Complex Extensive Tumors.

BACKGROUND: Spheno-orbital meningiomas (SOMs) are complex tumors involving the sphenoid wing, the orbit, and sometimes the cavernous sinus with bone hyperostosis and sheet-like dural involvement. Optimal removal, proptosis cure, and visual preservation remain a challenge. OBJECTIVE: To study the management of surgically treated SOMs. METHODS: The clinical records of 130 consecutive patients undergoing surgery for SOMs were retrospectively collected in a database during a 20-year period to analyze symptoms, surgical technique, clinical outcome, and follow-up. RESULTS: Among the 130 patients (mean age 51.2 ± 9.5 years), 91.5% were female. The most typical symptoms recorded were proptosis in 94.6%, visual impairment in 37.7%, and oculomotor paresis in 10.0%. Simpson grade I-II removal was achieved in 97 patients (74.6%). After 1 year, proptosis was improved in 60% of cases. A total of 44.9% of the patients with preoperative visual acuity impairment were improved. Periorbital excision was statistically linked to proptosis decreasing (P = 0.0001) and optic canal decompression was linked to visual stabilization (P = 0.03). Bone reconstruction prevented temporal muscle atrophy (P = 0.01) and unaesthetic results (P = 0.0001). Mean follow-up was 76.5 months (range 3-288 months), and the mean time for recurrence was 54.2 months. CONCLUSIONS: A single-stage optimal surgery with bone reconstruction appears to be the best first-line treatment, on a case-by-case analysis. Optic canal decompression and periorbital excision have to be performed in case of visual disturbance and proptosis. SOMs require a long-term follow-up because of a delayed high rate of recurrence.

Finding discriminative and interpretable patterns in sequences of surgical activities.

OBJECTIVE: Surgery is one of the riskiest and most important medical acts that is performed today. Understanding the ways in which surgeries are similar or different from each other is of major interest to understand and analyze surgical behaviors. This article addresses the issue of identifying discriminative patterns of surgical practice from recordings of surgeries. These recordings are sequences of low-level surgical activities representing the actions performed by surgeons during surgeries. MATERIALS AND METHOD: To discover patterns that are specific to a group of surgeries, we use the vector space model (VSM) which is originally an algebraic model for representing text documents. We split long sequences of surgical activities into subsequences of consecutive activities. We then compute the relative frequencies of these subsequences using the tf*idf framework and we use the Cosine similarity to classify the sequences. This process makes it possible to discover which patterns discriminate one set of surgeries recordings from another set. RESULTS: Experiments were performed on 40 neurosurgeries of anterior cervical discectomy (ACD). The results demonstrate that our method accurately identifies patterns that can discriminate between (1) locations where the surgery took place, (2) levels of expertise of surgeons (i.e., expert vs. intermediate) and even (3) individual surgeons who performed the intervention. We also show how the tf*idf weight vector can be used to both visualize the most interesting patterns and to highlight the parts of a given surgery that are the most interesting. CONCLUSIONS: Identifying patterns that discriminate groups of surgeon is a very important step in improving the understanding of surgical processes. The proposed method finds discriminative and interpretable patterns in sequences of surgical activities. Our approach provides intuitive results, as it identifies automatically the set of patterns explaining the differences between the groups.

Steroids in chronic subdural hematomas (SUCRE trial): study protocol for a randomized controlled trial.

BACKGROUND: Chronic subdural hematoma (CSDH) is a common neurological pathology, especially in older patients. The actual "gold standard" of treatment is surgical evacuation, with various techniques used across neurosurgical teams. Over the years, there has been growing evidence that inflammatory processes play a major role in the pathogenesis of CSDH. In that context, the use of corticosteroids has been proposed alone or as an adjuvant treatment to surgery. However, this practice remains very empirical and there is a need for high-quality-of-evidence studies to clarify the role of corticosteroids in the management of CSDH. METHODS/DESIGN: We propose a double-blind, randomized controlled trial comparing methylprednisolone versus placebo in the treatment of CSDH without clinical and/or radiological signs of severity. The treatment will be administered daily for a duration of 3 weeks, at a dose of 1 mg/kg. The primary endpoint will be the delay of occurrence of surgical treatment at 1 month following the introduction of the treatment. Secondary endpoints will include the rate of recourse to surgery, survival rate, quality of life and functional assessments, occurrence of systemic secondary effects and radiological assessment of the response to treatment. This multimodal assessment will be done at 1, 3 and 6 months. Two hundred and two patients (101 per arm) are expected to be included considering our primary hypotheses. DISCUSSION: This trial started in June 2016; its results may open interesting alternatives to surgery in the management of patients harboring a CSDH, and may provide insights into the natural history of this common pathology. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT02650609 . Registered on 4 January 2016. Graphical output of the OBF boundaries.

Intradiploic growing skull fracture: review of mechanisms and literature.

PURPOSE: A rare case of intradiploic growing fracture of the occipital bone is presented. Examination of this case and literature review was carried out to find significant specific features of such a rare condition. CASE: A 4-year-old boy was operated on for a huge occipital intradiploic growing skull fracture. His medical history, surgical management, and postoperative course are presented. LITERATURE REVIEW: A computer literature search using the Medline database revealed 31 well-documented cases. CONCLUSIONS: Special attention must be paid to skull fractures in childhood when occurring near CSF large spaces, especially if ventricle enlargement, suggesting that hydrocephalus is present. Surgeons should evaluate hydrocephalus before treating such lesions in order to improve surgical result and postoperative clinical evolution.

First case of disseminated infection with Nocardia cerradoensis in a human.

Here we report in a human, a renal transplant patient, the first disseminated infection with Nocardia cerradoensis, isolated after a brain biopsy. Species identification was based on 16S rRNA, gyrB, and hsp65 gene analyses. Antibiotic treatment was successful by combining carbapenems and aminoglycosides and then switching to oral trimethoprim-sulfamethoxazole.

Influence of cumulative surgical experience on the outcome of poor-grade patients with ruptured intracranial aneurysm.

BACKGROUND: The expansion of endovascular techniques for intracranial aneurysms has led to a global decrease in vascular neurosurgery activity. This situation might impact neurosurgeons' level of expertise, even though they all might have to deal with this surgically challenging pathology. In that context, we wanted to assess the impact of cumulative surgical experience on the outcome of patients with poor-grade subarachnoid haemorrhage (SAH) and intracerebral haemorrhage (ICH) treated by microsurgery. METHODS: Sixty-seven patients who underwent surgery for a ruptured aneurysm with SAH and ICH, and a WFNS scale of IV/V, were included. Surgeries were performed by five surgeons, whose experience was judged by the total number of aneurysm surgeries performed. The outcome was assessed by three indicators: intraoperative rupture (IOR), early mortality, and the modified Rankin Scale at last follow-up. The time of IOR was reported on an IOR score. The correlation between surgical experience and outcome was assessed by linear regression. Nonlinear regression was used to assess the correlation of the data with a learning curve model. RESULTS: The analysis showed an influence of surgical experience on intraoperative rupture, with no effect on long-term outcome. No influence was found on early mortality. Increased surgical experience seems to reduce IOR during aneurysm dissection and clip repositioning. Intraoperative rupture data fit Wright's learning curve model. CONCLUSION: This study suggests a direct impact of cumulative experience on the course of ruptured aneurysm surgery and pleads for the use of training and simulation programmes dedicated to neurovascular surgery.

Dynamic cervical myelopathy in young adults.

PURPOSE: Non-traumatic cervical chronic joint instability in young adults is a rare and underexplored entity. We assessed the diagnostic relevance of dynamic MRI, and the clinical and radiological outcome after anterior cervical interbody fusion (ACIF) in these cases. METHODS: Six young patients (mean age 34 years) with cervical myelopathy without compression on static imaging had a dynamic MRI. Joint instability was defined by a reduction of the canal diameter on dynamic sequences. Clinical and radiological outcomes were assessed after surgery by examination, cervical X-rays, static and dynamic MRI. RESULTS: All the patients had joint instability. Four patients underwent surgery. Clinical status improved 1 year after surgery. All patients had a satisfactory fusion at 6-month follow-up and no residual compression at 1 year. CONCLUSION: Dynamic MRI can help detect a joint instability in young patients with cervical myelopathy without compression. ACIF seems to be efficient in these cases.

Management of post-traumatic cerebrospinal fluid (CSF) leak of anterior skull base: 10 years experience.

CONCLUSION: Anterior skull base cerebrospinal fluid (CSF) leak should be surgically repaired with an endonasal approach first for less morbidity. Pretherapeutic topographical diagnosis increases the success rate of surgical repair. OBJECTIVES: We aimed to evaluate our efficiency in taking care of post-traumatic anterior skull base CSF leak, since no consensual algorithms for diagnosis and treatment have been established. METHODS: Data from 40 patients treated for post-traumatic CSF leak of the anterior skull base between January 1997 and December 2008 were retrospectively reviewed. Twenty-nine patients were treated with surgery, with an endonasal approach in 14 patients and a neurosurgical approach in 15 patients. A wait and see policy was applied in 11 patients. RESULTS: The overall risk of reccurence was 22.5%. Recurrence was represented by the presence of CSF rhinorrhea in 12.5% and the appearance of meningitis in 10% of patients. The overall risk of postoperative anosmia was 27.5%. A wait and see policy led to a higher risk of developing meningitis than surgical repair (p = 0.0003). The absence of pretherapeutic topographical diagnosis led to a higher risk of recurrence of CSF rhinorrhea (p = 0.01). The endonasal approach resulted in less postoperative anosmia (p = 0.006).

Sporadic intracranial haemangioblastomas: surgical outcome in a single institution series.

BACKGROUND: Haemangioblastomas are benign vascular tumours that may appear sporadically or in von Hippel-Lindau disease. Despite their higher incidence, sporadic haemangioblastomas have been less studied than syndromic ones. In this article, we evaluate the specific features, outcome and quality of life of patients with intracranial sporadic haemangioblastomas (ISHs) operated on in our institution. METHODS: Between 1998 and 2010, 38 patients harbouring 38 ISHs were operated on in our department. Their clinical, biological, radiological and surgical features were retrospectively reviewed. All patients were contacted for a quality-of-life (QOL) survey assessed by the Short Form 36 questionnaire (SF36). The mean duration of follow-up was 40 months (13-108 months). RESULTS: ISH represented 0.9 % of primary intracranial neoplasms treated in our centre during this period. Patients comprised 23 men and 15 women with a mean age of 47 years. None had polycythaemia. Cerebellar locations accounted for 79 % of ISHs, and brainstem ISH with involvement of the floor of the fourth ventricle represented 11 % of ISHs. At last follow-up, two patients harbouring solid medulla oblongata haemangioblastoma had died following severe bulbar syndrome and five patients had died of unrelated causes. One patient had multiple surgeries for three recurrences. Tumoral control was achieved in all cases at last follow-up. Results of the SF-36 questionnaire were as follows: median physical functioning score 100 (range 0-100), median physical problems score 100 (range 0-100), median bodily pain score 100 (range 45-100), median social functioning score 100 (range 25-100), median general mental health score 84 (range 40-92), median emotional problems score 100 (range 0-100), median vitality score 70 (range 35-80) and median general health perceptions score 70 (range 35-100). Mean QOL scores were similar to the general healthy population. CONCLUSION: Surgery of ISH provides good QOL and tumoral control except for those located in the medulla oblongata. We recommend considering a careful multimodal therapeutic approach, including radiosurgery for these specific locations.

Surgical treatment of rare cauda equina tumours.

BACKGROUND: Cauda equina tumours (CET) are rare and usually benign. Treatment of schwannomas and benign ependymomas, which are the most frequent histopathological types of CET, is now well established. However, management of other presumed histopathological types of CET is still a matter of debate. The aim of this study was to assess the incidence and the surgical treatment of rare CET. METHOD: A retrospective study was carried out on 176 adult patients surgically treated for CET in our two departments from 1994 to 2010. We reviewed pre- and postoperative symptoms, magnetic resonance imaging aspects, surgical findings, outcome including operative neurological morbidity, local recurrence rate and operative mortality, and incidence of rare CET. FINDINGS: Seventeen percent (30 patients) of CETs operated on were neither schwannomas nor benign ependymomas. Half of these cases were benign tumours, with paragangliomas being the most common. Two patients were in poorer clinical condition after surgery, one patient experienced a local recurrence, and one died following surgery, from the progress of his disease (Von Hippel-Lindau disease). The other half were malignant tumours, with metastases being the most common. One third of the patients were worsened by surgery, and the mortality rate was 1/3 at 8 months (1-27 months). CONCLUSIONS: Roughly one in six CET were neither schwannomas nor benign ependymomas. This study demonstrated the efficiency of surgery for rare benign CET with a low local recurrence rate. Surgical treatment of rare malignant CET led to a high rate of increased postoperative neurological deficit in patients with a reduced life expectancy.

Decision making during preoperative surgical planning.

OBJECTIVE: This study analyzes decision making during preoperative surgical planning through two cognitive indicators: conflict and cognitive control. BACKGROUND: Planning is a critical stage in naturalistic decision making, and there is some evidence suggesting that this activity depends on the level of expertise and the demands of the task. The specificity of surgery resides in the necessity to cope with (potential) conflicts between the purpose of the surgical intervention and the biological laws governing the patient's body. METHOD: Six neurosurgeons (two board-certified neurosurgeons, two chief residents, and two residents) described the operative procedure envisaged on nine surgical cases of increasing surgical complexity. A detailed analysis of one surgical case described by one expert was performed. Moreover, we measured the number of conflicts and controls reported by each surgeon. RESULTS: Two experts were the only ones for which the report of conflicts increased with surgical complexity (respectively, 75% and 73% of the conflict variance predicted by complexity). The two experts significantly activated a higher proportion of knowledge-based control (respectively, 43% and 38%) than did intermediates and residents. The residents significantly activated more motor skill-based controls (respectively, 40% and 44%) than did intermediates and experts. CONCLUSION: It seems that expert surgical decision making to cope with task demands is significantly associated with conflict monitoring. Knowledge-based control to regulate conflict is mainly produced by experts. APPLICATION: Conflicts and controls analyzed through verbal reports can be used as relevant indicators to highlight critical moments in decision making that potentially require assistance from information systems.

Acquired Chiari I malformation and syringomyelia after valveless lumboperitoneal shunt in infancy.

The authors present the case of a 13-year-old boy who experienced frequent disabling episodes of typical postural induced headaches, which revealed a Chiari I malformation, syringomyelia and cervical spinal cord edema. This boy had received a valveless lumboperitoneal (LP) shunt at the age of 18 months for macrocephaly. At this time, cranial CT scan showed moderate enlargement of the subarachnoid spaces without hydrocephalus or tonsillar herniation. The LP shunt was clamped but the patient experienced signs of brain stem dysfunction and increased intracranial pressure. Finally, an adjustable valve (110 mm Hg) was inserted and all the symptoms resolved. Although some authors consider LP shunt as a safe and effective procedure even in the pediatric population, our case reminds us that these shunts, especially when valveless, may expose the patient to the risk of symptomatic acquired Chiari I malformation and syringomyelia consecutive to a chronic spinal CSF leakage.

Brain shift is central to the pathogenesis of intracerebral haemorrhage remote from the site of the initial neurosurgical procedure.

Intracerebral haemorrhage remote from the site of surgery is an uncommon and poorly understood complication after neurosurgical procedures. Although patients under anticoagulant therapy or with perioperative elevated blood pressure are usually considered potentially at high risk of postoperative intracerebral haemorrhage, the aetiology is still unclear for patients without these predisposing factors. In this paper, we suggest that brain shift, unavoidably occurring during all neurosurgical procedures, might play a central role in the aetiology of postoperative remote intracerebral haemorrhage. Brain shift is mainly caused by gravity, aggressive intraoperative dehydration, and cerebrospinal fluid aspiration. Brain shift produces stretching and transient occlusion of the corticodural bridging veins draining into the peripheral dural sinus. Consequently, venous infarcts occur in the venous drainage territories and haemorrhagic transformation results when perfusion is re-established within ischemic tissue. To minimize brain shift and consequent risk of remote intracerebral haemorrhage, we recommend avoiding the use of hyperosmotic agents and cerebrospinal fluid drainage systems during neurosurgical procedures. Moderate head elevation during and immediately after surgery may improve cerebral venous drainage and reduces the risks of this life-threatening complication.