Telemedicine for Potential Application in Austere Military Environments: Neurosurgical Support for a Decompressive Craniectomy.

INTRODUCTION: The main goal of this study was to assess the feasibility of a head-mounted display (HMD) providing telemedicine neurosurgical support during a decompressive craniectomy by a military surgeon who is isolated from readily available neurosurgical care. The secondary aim was to assess the usability perceived by the military surgeon and to evaluate technical aspects of the head-mounted display. MATERIALS AND METHODS: After a standard concise lecture, 10 military surgeons performed a decompressive craniectomy on a AnubiFiX-embalmed post-mortem human head. Seven military surgeons used a HMD to receive telemedicine neurosurgical support. In the control group, three military surgeons performed a decompressive craniectomy without guidance. The performance of the decompressive craniectomy was evaluated qualitatively by the supervising neurosurgeon and quantified with the surgeons' operative performance tool. The military surgeons rated the usability of the HMD with the telehealth usability questionnaire. RESULTS: All military surgeons performed a decompressive craniectomy adequately directly after a standard concise lecture. The HMD was used to discuss potential errors and reconfirmed essential steps. The military surgeons were very satisfied with the HMD providing telemedicine neurosurgical support. Military surgeons in the control group were faster. The HMD showed no hard technical errors. CONCLUSIONS: It is feasible to provide telemedicine neurosurgical support with a HMD during a decompressive craniectomy performed by a non-neurosurgically trained military surgeon. All military surgeons showed competence in performing a decompressive craniectomy after receiving a standardized concise lecture. The use of a HMD clearly demonstrated the potential to improve the quality of these neurosurgical procedures performed by military surgeons.

How I do it: percutaneous transforaminal endoscopic discectomy for lumbar disk herniation.

BACKGROUND: Percutaneous transforaminal endoscopic discectomy (PTED) has emerged as a less invasive technique to treat symptomatic lumbar disk herniation (LDH). PTED is performed under local anesthesia with the advantage of immediate intraoperative feedback of the patient. In this paper, the technique is described as conducted in our hospital. METHODS: PTED is performed under local anesthesia in prone position on thoracopelvic supports. The procedure is explained stepwise: e.g. marking, incision, introduction of the 18-gauge needle and guidewire to the superior articular process, introduction of the TomShidi needle and foraminotomy up to 9 mm, with subsequently removal of disk material through the endoscope. Scar size is around 8 mm. CONCLUSION: PTED seems a promising alternative to conventional discectomy in patients with LDH and can be performed safely.

Percutaneous Nucleoplasty for the Treatment of a Contained Cervical Disk Herniation.

Cervical radiculopathy is characterized by compression of the roots of the nerve. When conservative treatment fails and symptoms persist or increase in severity, surgical treatment is considered. Anterior cervical discectomy with or without fusion is regarded as the standard treatment for cervical disk herniation. Recently, there is an evolving trend in spinal surgery towards less invasive techniques. Nucleoplasty is a minimally invasive technique in which radiofrequency technology is used for percutaneous decompression. During the last years nucleoplasty has been proven to be a safe and effective treatment to alleviate radiculopathy, caused by a contained disk herniation. Nucleoplasty is usually performed on an outpatient basis and is associated with a fast recovery time. This paper will describe the preoperative and postoperative management of cervical nucleoplasty as well as the surgical technique, accompanied by a video.

Anterior cervical discectomy without fusion for a symptomatic cervical disk herniation.

BACKGROUND: Cervical radiculopathy is characterized by dysfunction of the nerve root usually caused by a cervical disk herniation. The most important symptom is pain, radiating from the neck to the arm. When conservative treatment fails, surgical treatment is indicated to relieve symptoms. During the last decades, multiple fusion techniques have been developed, although without clinical evidence for added value of fusion over non-fusion. METHODS: The surgical procedure of anterior cervical discectomy without fusion is performed step by step, leading to removal of the entire intervertebral disk. CONCLUSION: Anterior cervical discectomy without fusion is a safe and effective treatment for cervical disk herniation.

Delayed appearance of the scaffolding proteins PSD-95 and Homer-1 at the developing rat calyx of Held synapse.

The calyx of Held synapse is a giant axosomatic synapse that acts as a fast relay in the sound localization circuit of the brainstem. In rodents it forms within a relatively brief period starting around the second postnatal day (P2). The relative timing of the formation of its pre- and the postsynaptic compartment are not yet known. By means of fluorescent immunohistochemistry in neonatal rats we therefore compared the developmental expression patterns of the vesicular glutamate transporter (VGLUT)-1 and the postsynaptic density scaffolding proteins Homer-1 and PSD-95 in the medial nucleus of the trapezoid body (MNTB). Before its formation, colocalized punctate staining of VGLUT-1 and Homer-1 or PSD-95 was observed on principal neurons, in agreement with earlier work showing that they are already innervated by fibers from the cochlear nucleus before the calyx forms. The expression of VGLUT-1 clusters within the nascent calyx of Held synapse preceded the expression of Homer-1 and PSD-95 clusters, as indicated by the presence of principal neurons with only a large contiguous cluster (LCC) of VGLUT-1 at P2-3, whereas no neurons with only an LCC for Homer-1 or PSD-95 were seen. At P3 the first principal neurons with both a pre- and a postsynaptic LCC were observed, and at P12 all principal neurons had both a pre- and a postsynaptic LCC. The relatively late appearance of Homer-1 and PSD-95 within the developing calyx of Held synapse suggests that they play a role in its stabilization and the recruitment of additional receptors to its postsynaptic density.