Spinal intradural microsurgery in a nascent neurosurgical department: Lessons learned from the first 25 cases.

BACKGROUND: Between 2017 and 2021, the newly established Department of Neurosurgery at Shaare Zedek Medical Center in Jerusalem, a high volume metropolitan hospital, operated on 25 intradural lesions in 24 patients (one patient had multiple tumors). In this retrospective study, we review results and lessons learned as experienced surgeons opened a new service line. METHODS: A multidisciplinary team was assembled and led by experienced neurosurgeons with skills in both microneurosurgery and complex spine care. Standard operative techniques were used. A chart review was done to assess complications and outcome. RESULTS: 25 lesions were reviewed in 24 patients (14 female; 10 male) between the ages of 11-82 years of age. In 14 cases, gross total resection (GTR) was achieved; 11 cases underwent partial resection. Of the 11 non-GTR cases, 3 were initially planned as biopsies. In one case, there was a significant neurologic decline directly related to surgery. In a separate case, there was iatrogenic instability, necessitating further treatment. CONCLUSIONS: We identify six lessons learned in a nascent neurosurgical department, noting that surgical excellence is of paramount importance, but that the surgeon must also expand his/her role from master technician to team leader. Both microsurgical expertise for neural anatomy and understanding of spinal biomechanics for osseous anatomy is mandatory for surgery of SIDT. This retrospective analysis of our case series demonstrates experienced neurosurgeons can successfully deploy a new service line for challenging cases to the benefit of the hospital and local community.

Non-invasive assessment of normal and impaired iron homeostasis in the brain.

Strict iron regulation is essential for normal brain function. The iron homeostasis, determined by the milieu of available iron compounds, is impaired in aging, neurodegenerative diseases and cancer. However, non-invasive assessment of different molecular iron environments implicating brain tissue's iron homeostasis remains a challenge. We present a magnetic resonance imaging (MRI) technology sensitive to the iron homeostasis of the living brain (the r1-r2* relaxivity). In vitro, our MRI approach reveals the distinct paramagnetic properties of ferritin, transferrin and ferrous iron ions. In the in vivo human brain, we validate our approach against ex vivo iron compounds quantification and gene expression. Our approach varies with the iron mobilization capacity across brain regions and in aging. It reveals brain tumors' iron homeostasis, and enhances the distinction between tumor tissue and non-pathological tissue without contrast agents. Therefore, our approach may allow for non-invasive research and diagnosis of iron homeostasis in living human brains.

[AUDITORY BRAINSTEM IMPLANTS (ABI) IN CHILDREN: CASE SERIES IN SHAARE ZEDEK MEDICAL CENTER].

BACKGROUND: Cochlear implants (CI) are the treatment of choice for individuals with severe to profound sensorineural hearing loss. A small group of patients, with pathology central to the cochlea, cannot benefit from CI. Examples in children include absence of the cochlear-nerve or cochlear aplasia. In these cases, implantation of an auditory brainstem implant (ABI), directly stimulating the cochlear nucleus, bypassing the inner-ear and auditory-nerve, may be beneficial. OBJECTIVES: Describe a series of children with ABI's treated in Shaare-Zedek, including the first ABI implantation in Israel (2017). METHODS: Of 9 patients with ABI's treated in Shaare Zedek Medical Center ,7 were children implanted between ages 2-8.6 years. Five boys and two girls. Surgeries were conducted in collaboration between neurosurgeons, neurotologists and audiologists (five implanted in Shaare-Zedek and two in New-York University). Follow-up was between 2-6 years. Hearing evaluation was conducted, mainly, with audiograms, categories of auditory performance (CAP), speech perception testing when possible and estimation of device use per day. RESULTS: Six of the seven children, who initially underwent unsuccessful CI, had deficient auditory-nerves. One child had cochlear-aplasia. In 3 children hearing loss was part of the CHARGE syndrome. CAP scores ranged from 0-7 (0,1,3,5,5,7). One child was able to achieve open-set speech perception. CONCLUSIONS: Although functional auditory outcomes for children with ABI are inferior to CI recipients and are highly variable, some children were able to obtain significant benefit. In these children, who are not candidates for CI, the ABI presents the only chance for auditory awareness and may be recommended. DISCUSSION: John Thomas Roland is a consultant and recipient of research support from Cochlear Americas.

Utility of MRI in surgical planning for parasagittal meningiomas.

BACKGROUND: Surgical resection is the standard treatment for parasagittal meningioma (PSM), but complete resection may be challenging due to superior sagittal sinus (SSS) involvement. The SSS may be partially or completely obstructed, and collateral veins are commonly present. Thus, knowing the status of the SSS in PSM cases prior to treatment is essential to a successful outcome. MRI is utilized prior to surgery in order to determine SSS status and to check for presence of collateral veins. The objective of this study is to evaluate the reliability of MRI in predicting both SSS involvement and presence of collateral veins in subsequent comparison to actual intra-operative findings, and to report on complications and outcomes. METHODS: 27 patients were retrospectively analyzed for this study. A blinded radiologist reviewed all pre-operative images, noting SSS status and collateral vein presence. Intraoperative findings were obtained from hospital records to similarly categorize SSS status and collateral vein presence. RESULTS: Sensitivity of the MRI to SSS status was found to be 100% and specificity was 93%. However, sensitivity and specificity of MRI to collateral vein presence was only 40% and 78.6%, respectively. Complications were experienced by 22% of patients, the majority neurologic in nature. CONCLUSION: MRI accurately predicted SSS occlusion status, but was less consistent in identification of collateral veins. These findings suggest MRI should be used with caution prior to PSM resection surgery particularly with regards to the presence of collateral veins which may complicate resection.

[ESTABLISHING A NEW TEAM FOR ENDOSCOPIC ENDONASAL SKULL BASE SURGERY: THE LEARNING CURVE FROM BASIC TO ADVANCED COMPLEXITY LEVEL].

INTRODUCTION: Establishing a new team for endoscopic endonasal skull base surgeries (EES) requires a period of adjustment. Our team was established 4 years ago and consists of surgeons with previous experience. Our objective was to examine the learning curve associated with the establishment of such a team. METHODS: All patients who underwent EES between January 2017 and October 2020 were reviewed. The first 40 patients were defined as the 'early group' and the last 40 as the 'late group'. Data was retrieved from electronic medical records and surgical videos. Study groups were compared in terms of the level of surgical complexity, (II to V according to EES complexity level scale; level I cases were excluded), surgical outcome and complication rate. RESULTS: 'Early group' cases and 'late group' cases were operated on in 25 and 11 months, respectively. Complexity level II surgeries, which mainly included pituitary adenomas, were the most common in both groups (77.5% and 60%, respectively); of these, functional adenomas and reoperations were more common in the 'late group'. The rate of advanced complexity surgeries (III - V) was higher in the 'late group' (40% vs. 22.5%); level V surgeries were performed only in the 'late group'. No significant differences were observed in terms of surgical outcomes or complications; postoperative cerebrospinal fluid (CSF) leaks were less common in the 'late group' (2.5% vs. 7.5%). CONCLUSIONS: Our findings indicate that the establishment of a new EES team, even if it includes experienced skull base surgeons, is associated with a learning curve, which requires about 40 cases.

[COMPARISON OF HIGH GAMMA ELECTROCORTICOGRAPHY AND DIRECT CORTICAL STIMULATION MAPPING OF CORTICAL FUNCTION IN AWAKE CRANIOTOMY: INITIAL EXPERIENCE].

INTRODUCTION: The use of intraoperative electrical cortical stimulation (ECS) to map function is the standard of care in modern neurosurgery. Recently, high gamma electrocorticography (hgECOG) mapping has had encouraging results. In this study we aim to compare hgECOG and fMRI with ECS for motor and language mapping. METHODS: We retrospectively evaluated medical records of patients who underwent awake surgery for tumor resection between January 2018 and December 2021. The first 10 consecutive patients who underwent ECS and hgECOG for mapping of motor and language functions were defined as the study group. Pre- and intra-operative imaging and electrophysiology data were used for analysis. RESULTS: ECS and hgECOG motor mapping demonstrated functional motor areas in 71.4% and 85.7% of patients, respectively. All motor areas identified with ECS were also demonstrated using hgECOG. In 2 patients, hgECOG-based mapping demonstrated motor areas not demonstrated with ECS but present in preoperative fMRI imaging. Of the 15 hgECOG tasks performed for language mapping, the findings of 6 (40%) were in accordance with the ECS mapping. Two (13.3%), showed language areas that were demonstrated using ECS and in addition, showed areas that were not. Four mappings (26.7%) showed language areas that were not demonstrated using ECS. In 3 mappings (20%), the functional areas identified by ECS were not demonstrated by hgECOG. CONCLUSIONS: Intraoperative hgECOG for mapping of motor and language functions provide a fast and reliable method without the risk of stimulation-induced seizures. Further studies are needed to assess functional outcome of patients undergoing hgECOG-guided tumor resection.

[INTRAOPERATIVE ELECTROPHYSIOLOGY MAPPING OF CORTICAL FUNCTION: A BRIEF HISTORY AND EVOLVING ALTERNATIVE].

INTRODUCTION: Multiple studies have demonstrated that the improved extent of resection for patients with glioma is associated with improved survival. The use of intraoperative electrophysiology cortical mapping to demonstrate function became a standard of care in modern neurosurgery and an indispensable tool to achieve the goal of maximal safe resection in tumor surgery. In this study, we review the brief history of intraoperative electrophysiology cortical mapping from the first cortical mapping study back in 1870 to the innovative tool of broad gamma cortical mapping used today.

Comparison of matched formalin-fixed paraffin embedded and fresh frozen meningioma tissue reveals bias in proteomic profiles.

Tissue biopsies are most commonly archived in a paraffin block following tissue fixation with formaldehyde (FFPE) or as fresh frozen tissue (FFT). While both methods preserve biological samples, little is known about how they affect the quantifiable proteome. We performed a 'bottom-up' proteomic analysis (N = 20) of short and long-term archived FFPE surgical samples of human meningiomas and compared them to matched FFT specimens. FFT facilitated a similar number of proteins assigned by MetaMorpheus compared with matched FFPE specimens (5378 vs. 5338 proteins, respectively (p = 0.053), regardless of archival time. However, marked differences in the proteome composition were apparent between FFPE and FFT specimens. Twenty-three percent of FFPE-derived peptides and 8% of FFT-derived peptides contained at least one chemical modification. Methylation and formylation were most prominent in FFPE-derived peptides (36% and 17% of modified FFPE peptides, respectively) while, most of phosphorylation and iron modifications appeared in FFT-derived peptides (p < 0.001). A mean 14% (± 2.9) of peptides identified in FFPE contained at least one modified Lysine residue. Importantly, larger proteins were significantly overrepresented in FFT specimens, while FFPE specimens were enriched with smaller proteins.

Skull Base Reconstruction with Multilayered Fascia Lata: A Single-Center 17 Years Experience.

Objective Reconstruction after open surgery of anterior skull base lesions is challenging. The fascia lata graft is our workhorse for achieving dural sealing and preventing cerebrospinal fluid leak and meningitis. This study seeks to analyze the donor and recipient site complication rates after fascia lata reconstruction. Methods This is a retrospective review of all open anterior skull base operations in which a double-layer fascia lata graft was used for the reconstruction of the defect from 2000 to 2016 at the Tel-Aviv Sourasky Medical Center, a tertiary referral center in Israel. Results Of the 369 patients operated for skull base lesions, 119 underwent open anterior skull base surgery and were reconstructed with a fascia lata graft. The patients' mean age was 47.1 years, and 68 (57.1%) were males. The overall postoperative early and late donor site complication rates were 6.7% ( n = 8) and 5.9% ( n = 7), respectively. Multivariate analysis found minor comorbidities and persistent/recurrent disease as being predictors for early-term complications. The overall postoperative early central nervous system (CNS) complication rate was 21.8% ( n = 26), while 12.6% ( n = 15) of the patients had late postoperative CNS complications. Conclusion Reconstruction of open anterior skull base lesions with fascia lata grafting is a safe procedure with acceptable complication and donor site morbidity rates.

Traumatic cerebral dural sinus vein thrombosis/stenosis in pediatric patients-is anticoagulation necessary?

INTRODUCTION: Cerebral dural vein thrombosis/stenosis (CDVT/S) is a condition that affects the venous drainage of the brain. Risk factors and causes associated with CDVT/S include systemic risk factors that cause hypercoagulability, or local factors such as head trauma. While consensus is that non-traumatic sinus vein thrombosis should be treated with anticoagulation therapy, treatment of patients with TBI-induced CDVT is not yet established. METHODS: Retrospective review of clinical data of pediatric patients presented to our medical center from July 2017 to August 2020. Inclusion criteria were age, birth to 18 years, admission due to head trauma, head CT scan with positive traumatic findings, and follow-up in our clinic. Exclusion criteria were a normal head CT on admission and failure to follow-up. Data regarding demographics, clinical presentation, imaging findings, treatment, and status on follow-up were recorded. Study protocol was approved by our institutional ethics committee. RESULTS: One hundred sixty-two patients were enrolled. Falling accident occurred in 90.1%, a minority suffered from direct head trauma or gunshot wound. Of the patients, 95.1% suffered from mild TBI. Forty-two percent suffered from an associated intracranial injury. Fourteen cases with CDVT were included in the cohort. Linear fractures were significantly correlated with CDVT. Additionally, occipital/suboccipital fractures, associated intracranial injury, and proximity of injury to the sinus were correlated with CDVT. From this group, 12 were treated conservatively; one patient was treated surgically due to EDH. All patients with CDVT were neurologically intact at discharge. Only one patient was treated with therapeutic dose of LMWH. A total of 86.7% of patients with CDVT who were treated conservatively had full recanalization on follow-up imaging. Four patients had CDVS; all were neurologically intact at admission and discharge, and all were treated conservatively and had full recanalization on follow-up. DISCUSSION: Treatment with ACT is established in pediatric CDVT but not in the sub-group of TBI. While ACT prevents progression of thrombosis, it might cause worsening of extra-axial hemorrhage. In our study, no clinical deterioration was noted with expectant management; thus, we present an algorithm for diagnosis and treatment of trauma-induced CDVT/S in children with frequent clinical and radiologic imaging while avoiding anticoagulation. CONCLUSION: In most cases, anticoagulation therapy is not necessary in traumatic CDVT/S. Initial expectant management in children is safe. However, each case should be evaluated individually and further studies should be performed.

Averting Delayed Complications of Open Anterior Skull Base Surgery.

Objective Despite its technical feasibility, anterior skull base surgery still carries the risk of severe postoperative complications, morbidity, and mortality. The reported rate of complications has diminished over the past two decades, but they continue to pose various challenges. This study aims to report late complications in a relatively large series of patients who underwent open anterior skull base surgery, and to propose methods for averting such complications. Methods Retrospective chart review of all patients who underwent anterior open skull base surgery between 2000 and 2016 in a university-affiliated tertiary referral cancer center. Results There were 301 operations, of which 198 (65.8%) were for benign disease and 103 (34.2%) were for malignant tumors. The male-to-female ratio was 1.4:1, and the mean age was 44.8 years. Delayed complications occurred in 85 patients (28.2%): 31 (10.3%) involved wounds, 18 (13.9%) involved the central nervous system, and 14 (4.6%) involved the orbit. Multivariate analysis found malignant pathology, intracranial extension, and previous radiochemotherapy as predictors for the development of a delayed complication. The patients who were operated in the later study period (after 2007) had lower rates of all three types of complications compared with the earlier study period. Conclusion Delayed complications following skull base surgery are in decline. This is mainly due to the advancement in imaging studies, surgical techniques, development of sophisticated reconstructive procedures, and the cooperation of multidisciplinary teams. We attribute the reduction in our department to our revised treatment protocol which is presented herein, with emphasis on averting the occurrence of these complications. Level of Evidence The level of evidence is 4.

The Outcome of Intracranial Meningioma Surgery in Octogenarians: Matched Cohort Study.

BACKGROUND: Previous studies compared outcomes of intracranial meningioma surgery in octogenarians with outcomes in younger patients without accounting for different tumor locations and sizes. The aim of the current study was to evaluate outcomes of intracranial meningioma surgery in octogenarians taking into account patient preoperative status and comorbidities as well as tumor properties. METHODS: The study cohort included all octogenarian patients who underwent elective craniotomies for intracranial meningiomas during 2008-2020 and patients <70 years old in the same time period matched for tumor size, tumor location, and preoperative Karnofsky scale score. Each group comprised 31 patients. Postoperative complications were divided into systemic, neurological, and wound related. Mortality and long-term complications were evaluated at 6-month follow-up. RESULTS: Mean age of patients was 82.6 ± 2.6 years for the study group and 57.9 ± 9.9 years for the control group (P < 0.0001). Two octogenarians (6.5%) died within 30 days after elective craniotomy compared with none in the younger group (P = 0.49). Mortality rates at 6 months were comparable between the 2 groups (12.9% vs. 3.2%, P = 0.35). There was no significant difference in overall postoperative complications between the octogenarian and control groups (77.4% vs. 74.2%, P = 0.77). American Society of Anesthesiologists score was the single predictor for any postoperative complications (odds ratio = 2.219, 95% confidence interval 1.024-4.811, P = 0.04). CONCLUSIONS: This study found no excess mortality or morbidity in octogenarians compared with younger patients. The American Society of Anesthesiologists score rather than age is a significant risk factor for overall morbidity and mortality following intracranial meningioma surgery in octogenarians.

When a Root Is the Cause of Infection.

BACKGROUND: Sinorhizobium meliloti is a phytobacterium found in the root nodules of plants, where it is involved in fixing nitrogen for delivery to the roots in exchange for a photosynthate carbon source. There have been no reported cases of S. meliloti infection in humans. We conducted a retrospective review of clinical records and diagnostic tests. CASE DESCRIPTION: An 81-year-old woman who presented to the emergency department with a 1-day history of progressive decline in her level of consciousness following a head injury and deep scalp laceration. Her medical history was significant for a ventriculoperitoneal shunt due to normal pressure hydrocephalus. Imaging studies revealed hydrocephalus and a tear in the shunt catheter. Cerebrospinal fluid analysis was not suggestive for meningitis. Cerebrospinal fluid culture revealed an unfamiliar organism, identified as S. meliloti following sequencing of its entire genome, which was considered a contaminant. The patient subsequently developed peritonitis, and the same pathogen was detected in the peritoneal fluid, suggesting distal shunt infection. Symptoms resolved after shunt removal and antibiotic treatment. Thorough history taking revealed that the patient had fallen and struck her head against a flowerpot. CONCLUSIONS: S. meliloti is a phytopathogen that should not be easily disregarded as a contaminant when isolated from human sterile fluids or tissues. Aggressive management including removal of infected hardware, if present, is required to ensure resolution of infection. It emphasizes the importance of thorough history taking.

Conservative management for pediatric patients with chiari 1 anomaly: A retrospective study.

OBJECTIVE: To better understand the natural history of non-surgical management of chiari 1 anomaly. PATIENTS AND METHODS: After obtaining approval of the institutional review board, medical records and radiological exams of patients treated for CM1 at our institution between the years 2010 and 2016 were reviewed. Twenty-nine patients total were included in our study. RESULTS: The average age of our patient population was 8.5 years old at the time of diagnosis. The average tonsillar herniation on first MRI was 9.4 mm (+/- 4.6) and the average tonsillar herniation on second MRI was 10.4 mm (+/- 4.8). The average follow up time of our sample of patients was 26 months. Of the 29 patients in our study 9 (31 %) had symptomatic presentation. Interestingly, four of our patients (13.8 %) presented with epilepsy. CONCLUSIONS: Our findings support the previous work that nonoperative management is best in asymptomatic or mildly symptomatic chiari patients.

Surgical approaches for infratemporal fossa tumor resection: Fifteen years' experience of a single center.

BACKGROUND: The aims of this study were to report our center's experience with infratemporal fossa (ITF) tumors, to review the treatment modalities and outcomes. METHODS: Data of patients that underwent resection of ITF tumors in a single tertiary referral medical center were collected and analyzed. RESULTS: Sixty-three patients were included. Sarcoma was the most common pathology (18; 29%). The most common surgical approach was the preauricular-orbitozygomatic approach (24; 38%), followed by endoscopic, craniofacial resection, and combined approaches. Forty-seven patients (75%) required reconstruction, 23 (49%) involving free tissue transfer. Thirty-five patients (76%) with malignant lesions required adjuvant therapy consisting of radiotherapy, chemotherapy, or both. Thirty-three patients suffered from complications related to surgery or adjuvant therapy. The three- and five-years survival rates for malignancy were 82% and 66%, respectively. CONCLUSION: Complete surgical resection of ITF involving tumors is feasible, providing good long-term survival. Multidisciplinary approach is the key for success.

Endoscopic skull base reconstruction with the nasoseptal flap: complications and risk factors.

PURPOSE: The endoscopic endonasal approach is increasingly being used for resection and reconstruction of anterior skull base lesions. The vascularized nasoseptal flap (NSF) has become the workhorse for reconstruction of anterior skull base defects, resulting in a significant decrease in the incidence of cerebrospinal fluid (CSF) leak. This study presents a single center's experience with NSFs and reports associated complications. METHODS: Patients who underwent endoscopic skull base defect repair with a NSF between 2008 and 2014 were retrospectively evaluated. Complications reviewed were divided into major and minor. Major complications included new-onset and continuing CSF leak and meningitis. Minor complications included long-standing crust formation, synechia, epistaxis, septal perforation, sinusitis and anosmia. RESULTS: Of the 77 patients included in the study, 47 (61%) underwent trans-sphenoidal surgery for pituitary lesions during which CSF leak was observed. The other 30 patients underwent reconstructive surgeries for post-traumatic CSF leaks or extirpation of lesions involving the anterior skull base. A high-flow intra-operative CSF leak was observed in 25 patients (25/77, 32%). The median follow-up was 16 months (range 3-81 months). 9 patients had major complications and 27 patients had minor complications. Only high-flow intra-operative CSF leak correlated with major complications (p = 0.012). CONCLUSION: NSF is an extremely effective tool for skull base reconstruction. While it is associated with a low rate of major complications, minor complications are frequent and require local treatment, although they tend to resolve in the late postoperative period.

Outcomes of Craniofacial Open Surgery in Octogenarians.

Introduction The steady increase in average life expectancy has led to a rise in the number of referrals of elderly patients for major operations. It is not clear whether age itself is a risk factor for morbidity and mortality after skull base operations. We investigated a possible link among a cohort of patients older than 80 years of age who underwent those surgeries in our department. Methods We conducted a retrospective analysis of all patients who underwent skull base surgery at the TASMC (Tel Aviv Sourasky Medical Center) between 2000 and 2016. Results A total of 369 patients underwent open skull base surgeries in our institution, and 13 were patients older than 80 years. The median age of the octogenarians was 83.4 (range 80-89), and the male-to-female ratio was 7:6. Twelve patients had major systemic comorbidities. Four patients had major complications associated with surgery: three had early wound complications, and one each had early central nervous system complications, early and late systemic complications, and late orbital complications. This complication rate is comparable to that of our younger group of 356 patients. The overall survival rate was measured for 30 days, 1 year, and 3 years, and it was not significantly different between the octogenarians and that of the younger patients. Further comparison of the elderly group with 13 matched younger patients revealed no difference of morbidity and mortality between the two groups. Conclusions Despite their systemic comorbidities, the morbidity and mortality rates associated with skull base surgery in octogenarians appear to be comparable to that of younger patients undergoing the same procedures.

Continuous lumbar drainage and the postoperative complication rate of open anterior skull base surgery.

OBJECTIVES/HYPOTHESIS: Anterior skull base operations pose the risk for postoperative cerebrospinal fluid (CSF) leak. Routine lumbar continuous drainage catheter (LD) placement is intended to decrease CSF leaks and central nervous system (CNS) complications, but there are no sound evidence-based data on its efficacy. The primary goal of this study was to review CNS complications following anterior open skull base surgery and their association with LD placement. The secondary goal was to define predictors for the development of early CNS complications. STUDY DESIGN: Retrospective case series. METHODS: We conducted a retrospective analysis of all patients who underwent anterior skull base surgery between 2000 and 2016 at the Tel Aviv Sourasky Medical Center, an Israeli tertiary referral center. RESULTS: A total of 226 patients underwent open skull base surgery, of whom 118 had elective perioperative continuous LD insertion and 108 did not. Delayed complications were defined as those occurring more than 30 days after the index operation. Thirty-one (26%) patients in the LD group had early CNS complications compared with only two (1.6%) in the non-LD group, whereas 13 (11%) of the former patients had late CNS complications compared with four (3%) of the latter patients. Early systemic and late wound complications were also significantly more numerous in the LD group. On multivariate analysis, elective LD insertion and intracranial tumor extension were found to be predictors for developing early CNS complications. CONCLUSIONS: The placement of continuous LDs might increase the risk of developing early and late CNS complications after open anterior skull base surgery. LEVEL OF EVIDENCE: 4 Laryngoscope, 128:2702-2706, 2018.

Enhanced visualization of the surgical field in pediatric direct laryngoscopy using a three-dimensional endoscopic system.

BACKGROUND: Direct laryngoscopy and rigid bronchoscopy are currently performed using 2-dimensional endoscopic systems. Our objective was to determine whether a 3-dimensional endoscopic system can enhance visualization of the surgical field in pediatric direct laryngoscopy and rigid bronchoscopy. METHODS: A prospective cohort study was conducted. Thirty three children who underwent direct laryngoscopies in a tertiary referral children's hospital were enrolled. Direct laryngoscopy was performed using both 2- and 3-dimensional endoscopic systems, after which the surgeons scored the quality of the images obtained with each system on a scale from 1 (low) to 5 (high). Comparison of the scores obtained with the 2 endoscopic systems was performed. RESULTS: The 33 study children (mean age 2.3 years, M:F ratio 1:1.6) underwent 47 direct laryngoscopies. The mean score for visualization of the glottis was 4.8 for the three-dimensional system compared to 4.0 for the two-dimensional system (P = .025), 4.7 vs. 3.8, respectively, (P = .019) for the subglottis, and 4.6 vs. 3.9, respectively (P = .031) for visualization of the proximal trachea. The mean score for visualization of the distal trachea was 3.0 vs. 3.7, respectively (P = .020). In a child with recurrent type 3 laryngotracheal cleft a residual tracheo-esophageal fistula could not be detected using the 2D system, but was immediately detected using the 3D system. CONCLUSIONS: Visualization of the glottis, subglottis and proximal trachea during direct laryngoscopy using a 3-dimensional endoscopic system was rated by the surgeons as being superior to the conventional 2-dimensional technique. Further outcome studies that will demonstrate the clinical advantage of the 3D technology are highly required. LEVEL OF EVIDENCE: 2b.