Intraoperative Ionizing Radiation Exposure Awareness and Associated Morbidity in Neurosurgery: A Nationwide Survey.

BACKGROUND: Neurosurgeons often use radiation to visualize blood vessels and implants intraoperatively. However, high exposure to radiation increases one's cancer risk. This study aims to investigate intraoperative ionizing radiation exposure awareness and associated morbidity among neurosurgeons. METHODS: An anonymized 30-question survey about their intraoperative radiation exposure, protective measures, radiation knowledge, and any conditions that can arise from protracted radiation exposure was disseminated to 3344 American Association of Neurological Surgeons members. RESULTS: A total of 227 (6.8%) neurosurgeons completed the survey. Most neurosurgeons (61, 27%) performed 2-4 surgeries per week necessitating radiation (61, 27%), did not use a dosimeter (134, 59%), and wore a lead apron (89%) and a thyroid shield (75%). Only 7 (3%) of respondents could correctly identify the safety limit for occupational radiation. One hundred and thirty-four (59%) respondents correctly identified the relationship between distance and radiation dose reduction. Two hundred and thirteen (94%) neurosurgeons reported concern about occupational radiation exposure. No significant association was found between occupational radiation exposure and the rate of cataracts, combined cancer, and skin cancer. Multivariate logistic regression adjusting for age and cancer history found that the likelihood of developing leukemia (P = 0.02) and nonmalignant thyroid nodular disease (P = 0.01) is positively associated with increased total occupational radiation exposure. CONCLUSIONS: There is a need for improved radiation safety awareness among neurosurgeons, especially in the context of rising usage of minimally invasive surgery. This can allow for a greater understanding of radiation-associated risks among neurosurgeons and guide the implementation of safer practices.

Quality of reporting for qualitative studies in pediatric urology-A scoping review.

INTRODUCTION: Qualitative research has gained popularity in pediatric urology due to rich data and insights about quantitative results. To date, there has been no study evaluating the comprehensiveness of the reporting of these studies based on established guidelines. OBJECTIVE: The objective of this study is to perform a scoping review of the quality of reporting in recent qualitative studies in pediatric urology based on a predominant checklist, the 21-item Standards of Reporting Qualitative Research (SRQR) and identify areas for improvement. STUDY DESIGN: In accordance with the Preferred Reported Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews, we performed a systematic literature search to identify qualitative studies on pediatric urology topics published from 2015 to 2021. We used clustering technology to eliminate articles with unrelated keywords. Articles not in English and those published prior to 2015 were excluded. Two reviewers performed title/abstract screening and full text review and resolved discrepancies by consensus. We reported the median and interquartile range of total SRQR scores (maximum: 21). SRQR-reported items were summarized; overall proportion of reported items for each article was estimated. Bivariate analyses examined the association between study characteristics and SRQR tertile. Simple linear regression was performed to examine the relationship between year and SRQR score. RESULTS: Of the 2562 titles/abstracts screened, 26 studies were included. The most common topics were hypospadias and congenital adrenal hyperplasia (Summary Figure). The median total score was 18.0 of 21 possible items (interquartile range: 3). All studies reported an abstract, problem formulation, purpose/context of the study, data collection methods, integration with prior work, limitations, and ethics review board approval. Most (25/26; 96.2%) reported sampling strategy, data analysis, synthesis/interpretation of findings and links to empirical data. Less fulfilled items included: a title identifying the study as qualitative (11/26, 42.3%), qualitative approach & research paradigm (11/26, 42.3%) and researcher characteristics & reflexivity (9/26, 34.6%). There was no association between study characteristics and SRQR score. There was a statistically significant increase in the SRQR score during the study period (ß = 1.0, p < 0.0001). DISCUSSION: Studies fulfilled most SRQR checklist items. There was significant improvement in quality during the study period. Limitations include possible recency bias and exclusion of articles due to inconsistent categorizations in Pub Med. CONCLUSION: The quality and trajectory of qualitative study reporting in pediatric urology is encouraging. SRQR standards should be implemented by journals to continue improving the robustness and transparency of future qualitative manuscripts in pediatric urology.

Multidrug-Resistant Trichomoniasis: Successful Treatment With 3 Months of Twice-Daily Intravaginal Boric Acid.

ABSTRACT: Trichomoniasis is the most common nonviral sexually transmitted infection. 1 For patients with resistance to standard treatment with 5-nitroimidazoles, alternative therapies are limited. We present a case of a 34-year-old woman with multidrug-resistant trichomoniasis who was successfully treated with 600 mg intravaginal boric acid twice daily for 3 months.

Characterizing and Improving Nomenclature for Reporting Lumbar Interbody Fusion Techniques.

OBJECTIVE: Lumbar interbody fusion (LIF) techniques have seen impressive innovation in recent years, leading to an expansion of the LIF lexicon. This study systematically analyzes LIF nomenclature in contemporary literature and proposes a standardized classification system for reporting LIF terminology. METHODS: A search query was conducted through the PubMed database using "lumbar fusion OR lumbar interbody fusion." A total of 1455 articles were identified, and 605 references to LIF were recorded. Following a systematic review of the terminology, we developed a LIF reporting guidelines that capture the existing LIF nomenclature while avoiding redundant or ambiguous terminology. RESULTS: The most referenced anatomical approaches were transforaminal (43.0%), followed by posterior (25.0%), lateral (19.7%), and anterior (10.9%). Overall, there were 72 unique ways to describe LIF. Unique prefixes were recorded by approach (posterior: 26; lateral: 13; anterior: 3). Forty unique prefixes/suffixes overlapped in their usage. "MI" (14.4%), "MIS" (38.1%), and "MISS" (0.6%) all referenced a minimally invasive approach. "O" (12.5%), "CO" (1.3%), and "TO" (1.3%) all described open techniques. "Endo" (0.6%), "Endoscopic-assisted" (1.3%), and "PE" (1.9%) all referenced endoscopic-assisted procedures. CONCLUSIONS: The current LIF nomenclature contains many unique LIF terms that were found to be inconsistently defined, redundant, or ambiguous. We propose the standardization of a 4-part naming system which highlights the crucial parts of LIF: (1) intraoperative repositioning, (2) patient position, (3) anatomical approach, and (4) orientation of the surgical corridor to the psoas muscles.

Virtual and Augmented Reality in Spine Surgery: A Systematic Review.

BACKGROUND: Augmented reality (AR) and virtual reality (VR) implementation in spinal surgery has expanded rapidly over the past decade. This systematic review summarizes the use of AR/VR technology in surgical education, preoperative planning, and intraoperative guidance. METHODS: A search query for AR/VR technology in spine surgery was conducted through PubMed, Embase, and Scopus. After exclusions, 48 studies were included. Included studies were then grouped into relevant subsections. Categorization into subsections yielded 12 surgical training studies, 5 preoperative planning, 24 intraoperative usage, and 10 radiation exposure. RESULTS: VR-assisted training significantly reduced penetration rates or increased accuracy rates compared to lecture-based groups in 5 studies. Preoperative VR planning significantly influenced surgical recommendations and reduced radiation exposure, operating time, and estimated blood loss. For 3 patient studies, AR-assisted pedicle screw placement accuracy ranged from 95.77% to 100% using the Gertzbein grading scale. Head-mounted display was the most common interface used intraoperatively followed by AR microscope and projector. AR/VR also had applications in tumor resection, vertebroplasty, bone biopsy, and rod bending. Four studies reported significantly reduced radiation exposure in AR group compared to fluoroscopy group. CONCLUSIONS: AR/VR technologies have the potential to usher in a paradigm shift in spine surgery. However, the current evidence indicates there is still a need for 1) defined quality and technical requirements for AR/VR devices, 2) more intraoperative studies that explore usage outside of pedicle screw placement, and 3) technological advancements to overcome registration errors via the development of an automatic registration method.

Standardizing Lumbar Interbody Fusion Nomenclature.

STUDY DESIGN: This article is a research methodology study. OBJECTIVE: We summarize current ambiguities and inaccuracies regarding lumbar interbody fusion nomenclature and propose a standardized reporting method to improve the clarity of future research and communication among spine surgeons and researchers. SUMMARY OF BACKGROUND DATA: Lumbar interbody fusion techniques have seen an impressive degree of refinement over recent years. This innovation has ushered in a plethora of naming conventions for these new surgical approaches. Many of the current trends in naming lumbar fusion techniques are, however, redundant and contradictory, creating unnecessary confusion in the field. METHODS: Following an extensive literature review, we developed a 4-part naming convention that highlights the crucial features of lumbar fusion surgical procedures. RESULTS: Current literature regarding lumbar fusions is rife with inconsistent usage and privatization of terminology that can inadvertently result in ambiguous operative vocabulary, potentially compromising the accuracy of future research. We propose a 4-part naming system that highlights crucial features of lumbar interbody fusions, including (1) intra-operative repositioning, (2) patient position, (3) surgical technique, and (4) orientation of the surgical corridor to the psoas muscle. CONCLUSIONS: This study raises awareness of current inconsistencies in naming conventions and proposes a standardized system for improving the clarity of lumber interbody fusion terminology for the broader spine community. LEVEL OF EVIDENCE: Level V.

Combined L5-S1 Anterior Lumbar Interbody Fusion and Multilevel Lateral Lumbar Interbody Fusion in a Single-Stage Lateral Decubitus Position Using Fluoroscopy-Based Instrument Tracking System.

Anterior lumbar interbody fusion (ALIF), traditionally performed supine, allows for significant restoration of lumbar lordosis, disc height, and foraminal height in degenerative spine diseases; however, an iatrogenic injury to the viscera and the great vessels can have devastating consequences. Although lateral lumbar interbody fusion (LLIF) is an acceptable and minimally invasive alternative at the L5-S1 level, this approach is suboptimal because of a narrow surgical corridor limited by the iliac crest, common iliac artery and vein, and psoas. Furthermore, combining supine L5-S1 ALIF and lateral decubitus (LD) LLIF requires time-consuming patient repositioning.1,2 To maximize the advantages of both procedures in patients with disease spanning the lumbosacral junction, ALIF and LLIF can be performed in a single stage with the patient remaining in an LD position throughout. To improve the efficiency of this single-position procedure, a fluoroscopy-based instrument tracking system (TrackX Technology Inc., Hillsborough, North Carolina, USA) was used to navigate surgical tools during the procedure. We show this technique in a 43-year-old patient with medically intractable back and leg pain secondary to multi-level degenerative lumbar spondylosis. The patient consented to this procedure; all participants consented to publication of their images. This tracking system allowed for accurate and precise virtual projections of surgical instruments, thereby facilitating the identification of midline and proper trajectories to perform discectomy and implant placement, reducing the amount of intraoperative fluoroscopy use, and eliminating intraoperative computed tomography. To our knowledge, this is the first operative video showing a fluoroscopy-based instrument tracking system used in a combined single-position LD-ALIF and LD-LLIF.

Qualitative research in pediatric urology.

INTRODUCTION: Qualitative studies have become increasingly common in the pediatric urology literature due to their ability to enhance our understanding of physicians' and patients' preferences, attitudes, and beliefs. The pediatric urology literature currently lacks clear guidelines for reporting qualitative research. In their absence, it is challenging to judge the quality of these studies. OBJECTIVES: The objectives of this educational article are to define what is involved in rigorous qualitative research studies, help readers recognize high-quality qualitative research, and provide practical skills in designing and implementing qualitative research. RESULTS: Acknowledging researcher biases, taking steps to reduce bias and increase reflexivity, and clear descriptions of research and data collection methods all contribute increased rigor and trustworthiness of qualitative studies. Proper selection of qualitative methodology, derived from the research question to be answered, establishes a foundation for reliable and meaningful data. CONCLUSION: As the field continues to grow, the standardization of reporting of these essential parameters becomes paramount so readers can gauge how findings can be appropriately applied to clinical practice.

Simultaneous Anterior Posterior Approach for Single-Position Lateral Lumbar Interbody Fusion with Robotic Assistance: Technical Guidelines and Early Outcomes.

BACKGROUND: Lumbar lateral interbody fusion (LLIF) is traditionally performed in 2 stages: placing the interbody cage in the lateral decubitus position, then placing the percutaneous pedicle screw in the prone position. Performing interbody fusion and posterior fixation simultaneously could improve operative efficiency and clinical outcomes associated with longer operative times. We describe the operative steps and report clinical and radiographic outcomes associated with a simultaneous anterior and posterior approach (SAPA) for LLIF. METHODS: Patients who underwent SAPA LLIF performed by a single surgeon over 1 year were retrospectively reviewed. Demographic, clinical, and radiographic data were analyzed, an operative guideline was created, and a learning curve was constructed using operative times. RESULTS: SAPA LLIF was performed in 11 patients. Three patients experienced transient postoperative femoral nerve plexopathy with symptoms of ipsilateral hip flexion weakness and/or anterior thigh numbness; there were no other complications in the cohort. Radiographically, patients achieved significant increases in disc height (8.3 mm vs. 13.5 mm, P = 0.002) and foraminal height (20.2 mm vs. 25.3 mm, P = 0.0001). Patients showed significant improvements in Oswestry Disability Index (52 vs. 27.8, P = 0.002) and Patient-Reported Outcome Measurement Information System Physical Function (32.6 vs. 39, P = 0.048) and Pain Interference (64.9 vs. 59.6, P = 0.001) at 3 months. A downward trend in operative time was observed for 1-level SAPA LLIF. CONCLUSIONS: SAPA LLIF is a safe approach for LLIF that results in favorable clinical outcomes. This technique can potentially improve operative efficiency further along the course of a surgeon's learning curve.

Understanding the Pathogenesis of Lateral Supratentorial Neurenteric Cysts in Close Proximity to Other Vascular Pathologies: A Case Report and Review of Embryology.

Several theories have been postulated to explain the embryogenesis of central nervous system (CNS) neurenteric cysts (NCs), but the exact mechanism remains poorly understood. Of those, the neurenteric canal migration hypothesis suggesting endodermal cell migration through the neurenteric canal and settling among ectodermal cells prior to neural tube closure might be the most robust as it explains, in contrast to other hypotheses, the existence of lateral supratentorial lesions, which are extremely rare, compared to their infratentorial counterparts. This mechanism might be supported by past medical history or the coexistence of CNS epidermoid cysts, which are thought to arise due to improper neural tube closure potentially increasing the probability of endodermal migration and subsequent NC development, yet there are no reported cases in the literature. We present a case of a patient with a history of a previously resected intracranial epidermoid cyst, representing three simultaneous pathologies including a laterally based right frontal NC along with a right corona radiata cavernous malformation lesion, and right middle cerebral artery bifurcation aneurysm. The three lesions were treated microsurgically in one operative session without complications. We discuss the case and review the relevant pathoembryology of laterally based supratentorial NC.

Minimally Invasive Deformity Correction Technique: Initial Case Series of Anterior Lumbar Interbody Fusion at L5-S1 for Multilevel Lumbar Interbody Fusion in a Lateral Decubitus Position.

OBJECTIVE: Many surgical options exist for multilevel lumbar interbody fusion, including anterior lumbar interbody fusion (ALIF) and lateral lumbar interbody fusion (LLIF). While current technique of repositioning patients between supine ALIF and lateral decubitus LLIF offers many benefits, intraoperative repositioning can be cumbersome. We present a novel approach that accomplishes both multilevel LLIF and L5-S1 ALIF in a lateral decubitus position. METHODS: This case series retrospectively enrolled 12 consecutive patients who underwent L5-S1 ALIF in the lateral decubitus position and anterior-to-psoas LLIF at more cranial levels as part of a multilevel lumbar interbody fusion surgery between September 2020 and December 2021. All surgeries were performed by a single spine-focused neurosurgeon at an urban academic hospital. RESULTS: Radiographic imaging analysis demonstrated significant changes in coronal Cobb angle (-5.43° ± 3.81°; P = 0.0029), global lumbar lordosis (6.77° ± 12.04°; P = 0.0049), segmental lumbar lordosis (8.91° ± 10.21°; P = 0.0005), spinopelvic mismatch (-7.93° ± 7.91°; P = 0.0010), average disc height (5.30 ± 1.64 mm; P = 0.0005), and L5-S1 disc height (6.68 ± 2.10 mm; P = 0.0005). Two patients developed postoperative complications including wound dehiscence and grade I graft subsidence at L4-L5. CONCLUSIONS: This case series demonstrated that a combined lateral decubitus L5-S1 ALIF and LLIF at more cranial levels is a safe, efficient approach to multilevel lumbar interbody fusions. This technique significantly restored spinopelvic alignments with a low complication rate and no patient repositioning. Efficacy of this minimally invasive deformity correction technique should be further investigated through a multicenter trial.

Acanthamoeba scleral abscess reoccurring after penetrating keratoplasty.

Two months following penetrating keratoplasty for Acanthamoeba keratitis, a 76-year-old man was referred due to inability to wean high-dose topical steroids. Despite a very healthy graft and minimal pain, a scleral abscess involving three clock hours of the superior conjunctiva was present. The patient underwent conjunctival and scleral excision of the area of apparent infection with adjuvant mitomycin C and double freeze-thaw cryotherapy treatment followed by amniotic membrane graft. Recurrence was confirmed with PCR. Following a multimonth regimen of oral voriconazole and topical polyhexamethylene biguanide, chlorhexidine and moxifloxacin, the patient was weaned from all anti-infectious agents. After cataract surgery and scleral lens fitting, the patient is now 20/20 in the affected eye. This case highlights the need for judicious use of immunosuppressive agents as well as the necessary vigilance to monitor for recurrence with Acanthamoeba infection. It also represents the first reported use of adjuvant mitomycin C and double freeze-thaw cryotherapy for treatment of Acanthamoeba scleral abscess.