Large symptomatic sacral Tarlov cyst in a paediatric patient: case report and technical note on a new variation of surgical technique to overcome one-way check-valve mechanism.

PURPOSE: Symptomatic Tarlov cysts in children with a possible underlying one-way check-valve mechanism are very rare. We aim to introduce a new variation of the surgical technique to overcome a check-valve mechanism. METHODS: A 15-years-old girl presented with double incontinence and anogenital numbness due to a large sacral Tarlov-cyst with possibly underlying one-way check valve mechanisms as suggested by preoperative computed tomography myelography. Intraoperatively, one-way check-valve was confirmed and could be eliminated by creating an artificial inner ostium between the Tarlov cyst and thecal sac with blunt perforation. RESULTS: Postoperatively, the patient had established normal sphincter control and sensation in the anogenital region. CONCLUSION: One-way check-valve mechanism might contribute to the symptomatology of large sacral Tarlov cysts in children. Our new variation of a surgical technique enables elimination of the check-valve mechanism without the necessity to open and close the typically very thin and fragile cyst surface and is therefore an efficacious and simple option in this situation.

Early evaluation of a natural language processing tool to improve access to educational resources for surgical patients.

PURPOSE: Accessible patient information sources are vital in educating patients about the benefits and risks of spinal surgery, which is crucial for obtaining informed consent. We aim to assess the effectiveness of a natural language processing (NLP) pipeline in recognizing surgical procedures from clinic letters and linking this with educational resources. METHODS: Retrospective examination of letters from patients seeking surgery for degenerative spinal disease at a single neurosurgical center. We utilized MedCAT, a named entity recognition and linking NLP, integrated into the electronic health record (EHR), which extracts concepts and links them to systematized nomenclature of medicine-clinical terms (SNOMED-CT). Investigators reviewed clinic letters, identifying words or phrases that described or identified operations and recording the SNOMED-CT terms as ground truth. This was compared to SNOMED-CT terms identified by the model, untrained on our dataset. A pipeline linking clinic letters to patient-specific educational resources was established, and precision, recall, and F1 scores were calculated. RESULTS: Across 199 letters the model identified 582 surgical procedures, and the overall pipeline after adding rules a total of 784 procedures (precision = 0.94, recall = 0.86, F1 = 0.91). Across 187 letters with identified SNOMED-CT terms the integrated pipeline linking education resources directly to the EHR was successful in 157 (78%) patients (precision = 0.99, recall = 0.87, F1 = 0.92). CONCLUSIONS: NLP accurately identifies surgical procedures in pre-operative clinic letters within an untrained subspecialty. Performance varies among letter authors and depends on the language used by clinicians. The identified procedures can be linked to patient education resources, potentially improving patients' understanding of surgical procedures.

Can ChatGPT outperform a neurosurgical trainee? A prospective comparative study.

PURPOSE: This study aimed to compare the performance of ChatGPT, a large language model (LLM), with human neurosurgical applicants in a neurosurgical national selection interview, to assess the potential of artificial intelligence (AI) and LLMs in healthcare and provide insights into their integration into the field. METHODS: In a prospective comparative study, a set of neurosurgical national selection-style interview questions were asked to eight human participants and ChatGPT in an online interview. All participants were doctors currently practicing in the UK who had applied for a neurosurgical National Training Number. Interviews were recorded, anonymised, and scored by three neurosurgical consultants with experience as interviewers for national selection. Answers provided by ChatGPT were used as a template for a virtual interview. Interview transcripts were subsequently scored by neurosurgical consultants using criteria utilised in real national selection interviews. Overall interview score and subdomain scores were compared between human participants and ChatGPT. RESULTS: For overall score, ChatGPT fell behind six human competitors and did not achieve a mean score higher than any individuals who achieved training positions. Several factors, including factual inaccuracies and deviations from expected structure and style may have contributed to ChatGPT's underperformance. CONCLUSIONS: LLMs such as ChatGPT have huge potential for integration in healthcare. However, this study emphasises the need for further development to address limitations and challenges. While LLMs have not surpassed human performance yet, collaboration between humans and AI systems holds promise for the future of healthcare.

Optimising trajectory planning for stereotactic brain tumour biopsy using artificial intelligence: a systematic review of the literature.

PURPOSE: Despite advances in technology, stereotactic brain tumour biopsy remains challenging due to the risk of injury to critical structures. Indeed, choosing the correct trajectory remains essential to patient safety. Artificial intelligence can be used to perform automated trajectory planning. We present a systematic review of automated trajectory planning algorithms for stereotactic brain tumour biopsies. METHODS: A PRISMA adherent systematic review was conducted. Databases were searched using keyword combinations of 'artificial intelligence', 'trajectory planning' and 'brain tumours'. Studies reporting applications of artificial intelligence (AI) to trajectory planning for brain tumour biopsy were included. RESULTS: All eight studies were in the earliest stage of the IDEAL-D development framework. Trajectory plans were compared through a variety of surrogate markers of safety, of which the minimum distance to blood vessels was the most common. Five studies compared manual to automated planning strategies and favoured automation in all cases. However, this comes with a significant risk of bias. CONCLUSIONS: This systematic review reveals the need for IDEAL-D Stage 1 research into automated trajectory planning for brain tumour biopsy. Future studies should establish the congruence between expected risk of algorithms and the ground truth through comparisons to real world outcomes.

How to use lumbar puncture manometry in children.

Measurement of cerebrospinal fluid pressure through lumbar puncture (LP) manometry is an essential practical skill all paediatricians should possess competency in. The ability to perform manometry is crucial in the diagnosis of idiopathic intracranial hypertension and can provide critical information on raised (or lowered) intracranial pressure in other clinical scenarios. Practitioners should be familiar with the procedure and in particular with equipment available to them locally. In this article, we will describe an approach to LP manometry. The online supplemental material includes an instructional video as well as supporting practical information.

Pulsatile versus non-pulsatile tinnitus in idiopathic intracranial hypertension.

INTRODUCTION: Tinnitus is a symptom commonly associated with idiopathic intracranial hypertension (IIH) that can have a profound effect on quality of life. We aim to determine tinnitus symptom response after dural venous sinus stenting (DVSS) or CSF diversion with a shunt, in patients with both pulsatile (PT) and non-pulsatile tinnitus (NPT). METHODS: Single-centre cohort of IIH patients (2006-2016) who underwent 24-h ICP monitoring (ICPM). An un-paired t test compared ICP and pulse amplitude (PA) values in IIH patients with PT vs. NPT. RESULTS: We identified 59 patients with IIH (56 F:3 M), mean age 32.5 ± 9.49 years, 14 of whom suffered from tinnitus. Of these 14, seven reported PT and seven reported NPT. Patients with tinnitus had a mean 24-h ICP and PA of 9.09 ± 5.25 mmHg and 6.05 ± 1.07 mmHg respectively. All 7 patients with PT showed symptom improvement or resolution after DVSS (n = 4), secondary DVSS (n = 2) or shunting (n = 1). In contrast, of the 7 with NPT, only 1 improved post intervention (DVSS), despite 2 patients having shunts and 5 having DVSS. CONCLUSIONS: NPT and PT were equally as common in our group of IIH patients. DVSS appears to be an effective management option for IIH patients with a clear history of pulsatile tinnitus. However, non-pulsatile tinnitus was more persistent and did not respond well to either DVSS or CSF diversion.

Process analysis of the patient pathway for automated data collection: an exemplar using pituitary surgery.

Introduction: Automation of routine clinical data shows promise in relieving health systems of the burden associated with manual data collection. Identifying consistent points of documentation in the electronic health record (EHR) provides salient targets to improve data entry quality. Using our pituitary surgery service as an exemplar, we aimed to demonstrate how process mapping can be used to identify reliable areas of documentation in the patient pathway to target structured data entry interventions. Materials and methods: This mixed methods study was conducted in the largest pituitary centre in the UK. Purposive snowball sampling identified frontline stakeholders for process mapping to produce a patient pathway. The final patient pathway was subsequently validated against a real-world dataset of 50 patients who underwent surgery for pituitary adenoma. Events were categorized by frequency and mapped to the patient pathway to determine critical data points. Results: Eighteen stakeholders encompassing all members of the multidisciplinary team (MDT) were consulted for process mapping. The commonest events recorded were neurosurgical ward round entries (N = 212, 14.7%), pituitary clinical nurse specialist (CNS) ward round entries (N = 88, 6.12%) and pituitary MDT treatment decisions (N = 88, 6.12%) representing critical data points. Operation notes and neurosurgical ward round entries were present for every patient. 43/44 (97.7%) had a pre-operative pituitary MDT entry, pre-operative clinic letter, a post-operative clinic letter, an admission clerking entry, a discharge summary, and a post-operative histopathology pituitary multidisciplinary (MDT) team entries. Conclusion: This is the first study to produce a validated patient pathway of patients undergoing pituitary surgery, serving as a comparison to optimise this patient pathway. We have identified salient targets for structured data entry interventions, including mandatory datapoints seen in every admission and have also identified areas to improve documentation adherence, both of which support movement towards automation.

Benchtop simulation of the retrosigmoid approach: Validation of a surgical simulator and development of a task-specific outcome measure score.

Background: Neurosurgical training is changing globally. Reduced working hours and training opportunities, increased patient safety expectations, and the impact of COVID-19 have reduced operative exposure. Benchtop simulators enable trainees to develop surgical skills in a controlled environment. We aim to validate a high-fidelity simulator model (RetrosigmoidBox, UpSurgeOn) for the retrosigmoid approach to the cerebellopontine angle (CPA). Methods: Novice and expert Neurosurgeons and Ear, Nose, and Throat surgeons performed a surgical task using the model - identification of the trigeminal nerve. Experts completed a post-task questionnaire examining face and content validity. Construct validity was assessed through scoring of operative videos employing Objective Structured Assessment of Technical Skills (OSATS) and a novel Task-Specific Outcome Measure score. Results: Fifteen novice and five expert participants were recruited. Forty percent of experts agreed or strongly agreed that the brain tissue looked real. Experts unanimously agreed that the RetrosigmoidBox was appropriate for teaching. Statistically significant differences were noted in task performance between novices and experts, demonstrating construct validity. Median total OSATS score was 14/25 (IQR 10-19) for novices and 22/25 (IQR 20-22) for experts (p < 0.05). Median Task-Specific Outcome Measure score was 10/20 (IQR 7-17) for novices compared to 19/20 (IQR 18.5-19.5) for experts (p < 0.05). Conclusion: The RetrosigmoidBox benchtop simulator has a high degree of content and construct validity and moderate face validity. The changing landscape of neurosurgical training mean that simulators are likely to become increasingly important in the delivery of high-quality education. We demonstrate the validity of a Task-Specific Outcome Measure score for performance assessment of a simulated approach to the CPA.

A synthetic model simulator for intracranial aneurysm clipping: validation of the UpSurgeOn AneurysmBox.

Background and objectives: In recent decades, the rise of endovascular management of aneurysms has led to a significant decline in operative training for surgical aneurysm clipping. Simulation has the potential to bridge this gap and benchtop synthetic simulators aim to combine the best of both anatomical realism and haptic feedback. The aim of this study was to validate a synthetic benchtop simulator for aneurysm clipping (AneurysmBox, UpSurgeOn). Methods: Expert and novice surgeons from multiple neurosurgical centres were asked to clip a terminal internal carotid artery aneurysm using the AneurysmBox. Face and content validity were evaluated using Likert scales by asking experts to complete a post-task questionnaire. Construct validity was evaluated by comparing expert and novice performance using the modified Objective Structured Assessment of Technical Skills (mOSATS), developing a curriculum-derived assessment of Specific Technical Skills (STS), and measuring the forces exerted using a force-sensitive glove. Results: Ten experts and eighteen novices completed the task. Most experts agreed that the brain looked realistic (8/10), but far fewer agreed that the brain felt realistic (2/10). Half the expert participants (5/10) agreed that the aneurysm clip application task was realistic. When compared to novices, experts had a significantly higher median mOSATS (27 vs. 14.5; p < 0.01) and STS score (18 vs. 9; p < 0.01); the STS score was strongly correlated with the previously validated mOSATS score (p < 0.01). Overall, there was a trend towards experts exerting a lower median force than novices, however, these differences were not statistically significant (3.8 N vs. 4.0 N; p = 0.77). Suggested improvements for the model included reduced stiffness and the addition of cerebrospinal fluid (CSF) and arachnoid mater. Conclusion: At present, the AneurysmBox has equivocal face and content validity, and future versions may benefit from materials that allow for improved haptic feedback. Nonetheless, it has good construct validity, suggesting it is a promising adjunct to training.

Neurosurgical Team Acceptability of Brain-Computer Interfaces: A Two-Stage International Cross-Sectional Survey.

OBJECTIVE: Invasive brain-computer interfaces (BCIs) require neurosurgical implantation, which confers a range of risks. Despite this situation, no studies have assessed the acceptability of invasive BCIs among the neurosurgical team. This study aims to establish baseline knowledge of BCIs within the neurosurgical team and identify attitudes toward different applications of invasive BCI. METHODS: A 2-stage cross-sectional international survey of the neurosurgical team (neurosurgeons, anesthetists, and operating room nurses) was conducted. Results from the first, qualitative, survey were used to guide the second-stage quantitative survey, which assessed acceptability of invasive BCI applications. Five-part Likert scales were used to collect quantitative data. Surveys were distributed internationally via social media and collaborators. RESULTS: A total of 108 qualitative responses were collected. Themes included the promise of BCIs positively affecting disease targets, concerns regarding stability, and an overall positive emotional reaction to BCI technology. The quantitative survey generated 538 responses from 32 countries. Baseline knowledge of BCI technology was poor, with 9% claiming to have a good or expert knowledge of BCIs. Acceptability of invasive BCI for rehabilitative purposes was >80%. Invasive BCI for augmentation in healthy populations divided opinion. CONCLUSIONS: The neurosurgical team's view of the acceptability of invasive BCI was divided across a range of indications. Some applications (e.g., stroke rehabilitation) were viewed as more appropriate than other applications (e.g., augmentation for military use). This range in views highlights the need for stakeholder consultation on acceptable use cases along with regulation and guidance to govern initial BCI implantations if patients are to realize the potential benefits.

Characterization of patients with idiopathic normal pressure hydrocephalus using natural language processing within an electronic healthcare record system.

OBJECTIVE: Idiopathic normal pressure hydrocephalus (iNPH) is an underdiagnosed, progressive, and disabling condition. Early treatment is associated with better outcomes and improved quality of life. In this paper, the authors aimed to identify features associated with patients with iNPH using natural language processing (NLP) to characterize this cohort, with the intention to later target the development of artificial intelligence-driven tools for early detection. METHODS: The electronic health records of patients with shunt-responsive iNPH were retrospectively reviewed using an NLP algorithm. Participants were selected from a prospectively maintained single-center database of patients undergoing CSF diversion for probable iNPH (March 2008-July 2020). Analysis was conducted on preoperative health records including clinic letters, referrals, and radiology reports accessed through CogStack. Clinical features were extracted from these records as SNOMED CT (Systematized Nomenclature of Medicine Clinical Terms) concepts using a named entity recognition machine learning model. In the first phase, a base model was generated using unsupervised training on 1 million electronic health records and supervised training with 500 double-annotated documents. The model was fine-tuned to improve accuracy using 300 records from patients with iNPH double annotated by two blinded assessors. Thematic analysis of the concepts identified by the machine learning algorithm was performed, and the frequency and timing of terms were analyzed to describe this patient group. RESULTS: In total, 293 eligible patients responsive to CSF diversion were identified. The median age at CSF diversion was 75 years, with a male predominance (69% male). The algorithm performed with a high degree of precision and recall (F1 score 0.92). Thematic analysis revealed the most frequently documented symptoms related to mobility, cognitive impairment, and falls or balance. The most frequent comorbidities were related to cardiovascular and hematological problems. CONCLUSIONS: This model demonstrates accurate, automated recognition of iNPH features from medical records. Opportunities for translation include detecting patients with undiagnosed iNPH from primary care records, with the aim to ultimately improve outcomes for these patients through artificial intelligence-driven early detection of iNPH and prompt treatment.

Artificial Intelligence in Brain Tumour Surgery-An Emerging Paradigm.

Artificial intelligence (AI) platforms have the potential to cause a paradigm shift in brain tumour surgery. Brain tumour surgery augmented with AI can result in safer and more effective treatment. In this review article, we explore the current and future role of AI in patients undergoing brain tumour surgery, including aiding diagnosis, optimising the surgical plan, providing support during the operation, and better predicting the prognosis. Finally, we discuss barriers to the successful clinical implementation, the ethical concerns, and we provide our perspective on how the field could be advanced.

Early Postoperative Outcomes of Normal Pressure Hydrocephalus: Results of a Service Evaluation.

BACKGROUND: Patients with normal pressure hydrocephalus (NPH) are often elderly, frail and affected by multimorbidity. Treatment is surgical with cerebrospinal diversion shunts. The selection of patients that are of an acceptable level of risk to be treated surgically has been a matter of debate for years and has deprived some patients of life-changing surgery. The aim of this service evaluation was to investigate the preoperative risk factors and early postoperative morbidity of patients with NPH using a standardized postoperative survey. MATERIALS AND METHODS: Consecutive NPH patients admitted for neurosurgical management of NPH between May 2017 and May 2018 were included in this prospective service evaluation. In addition to the collection of traditional outcome measures, the cardiac version of the Postoperative Morbidity Survey (C-POMS) was conducted on postoperative days 4, 7, and 10 to identify postoperative morbidity. RESULTS: Eighty-eight patients (63 males, age mean±SD, 75±7 y) underwent 106 surgical procedures (61 lumbar drains, 45 ventriculoperitoneal shunts). There was no 30-day mortality and no unexpected return to the operating room or admission to intensive care unit. There was 1 conservatively managed surgical complication. On postoperative day 4, the C-POMS identified no postoperative morbidity in 72% of the patients, and mild morbidity (postoperative nausea and mobility issues) in 28%. There was a delay in discharge in 50% of the patients with no postoperative morbidity on day 4, highlighting areas of our service requiring improvement. CONCLUSIONS: Early postoperative outcomes of NPH patients are good after both ventriculoperitoneal shunt insertion and lumbar drainage. This evaluation provides initial evidence on the utility of the C-POMS as a service evaluation tool in the standardized assessment postoperative outcomes in neurosurgery patients.