Digital exoscope versus surgical microscope in spinal dural arteriovenous fistula surgery: a comparative series.

OBJECTIVE: Surgical treatment of spinal dural arteriovenous fistulas (DAVFs) has been reported to be superior to endovascular treatment in terms of occlusion of the fistula. Despite the increased availability of digital 3D exoscopes, the potential benefits of using an exoscope in spinal DAVF surgery have not been studied. The purpose of this study was to report and compare the results of exoscope- and microscope-assisted surgery for spinal DAVFs. METHODS: All consecutive adult patients (≥ 18 years of age) treated surgically for spinal DAVFs from January 2016 to January 2023 in a tertiary neurosurgical referral center were included. All patients were operated on by one neurosurgeon. Their pre- and postoperative clinical findings, imaging studies, and intra- and postoperative events were evaluated and surgical videos from the operations were analyzed. RESULTS: Altogether, 14 patients received an operation for spinal DAVF during the study period, 10 (71%) with an exoscope and 4 (29%) with a microscope. The DAVFs were most commonly located in the lower parts of the thoracic spine in both groups. The duration of exoscopic surgeries was shorter (141 vs 151 minutes) and there was less blood loss (60 vs 100 ml) than with microscopic surgeries. No major surgical complications were observed in either group. Of the 14 patients, 10 had gait improvement postoperatively: 7 (78%) patients in the exoscope group and 3 (75%) in the microscope group. None of the patients experienced deterioration following surgery. CONCLUSIONS: Exoscope-assisted surgery for spinal DAVFs is comparable in safety and effectiveness to traditional microscopic surgery. With practice, experienced neurosurgeons can adapt to using the exoscope without major additional risks to the patient.

Even short-term training improves the skills of novice exoscope users: a prospective laboratory experiment.

BACKGROUND: The surgical 3D exoscopes have recently been introduced as an alternative to the surgical microscopes in microneurosurgery. Since the exoscope availability is still limited, it is relevant to know whether even a short-term exoscope training develops the skills needed for performing exoscope-assisted surgeries. METHODS: Ten participants (six consultants, four residents) performed two laboratory bypass test tasks with a 3D exoscope (Aesculap Aeos®). Six training sessions (6 h) were performed in between (interval of 2-5 weeks) on artificial models. The participants were divided into two groups: test group (n = 6) trained with the exoscope and control group (n = 4) with a surgical microscope. The test task was an artificial end-to-side microsurgical anastomosis model, using 12 interrupted 9-0 sutures and recorded on video. We compared the individual as well as group performance among the test subjects based on suturing time, anastomosis quality, and manual dexterity. RESULTS: Altogether, 20 bypass tasks were performed (baseline n = 10, follow-up n = 10). The median duration decreased by 28 min and 44% in the exoscope training group. The decrease was steeper (29 min, 45%) among the participants with less than 6 years of microneurosurgery experience compared to the more experienced participants (13 min, 24%). After training, the participants with at least 1-year experience of using the exoscope did not improve their task duration. The training with the exoscope led to a greater time reduction than the training with the microscope (44% vs 17%). CONCLUSIONS: Even short-term training with the exoscope led to marked improvements in exoscope-assisted bypass suturing among novice microneurosurgeons. For the more experienced participants, a plateau in the initial learning curve was reached quickly. A much longer-term effort might be needed to witness further improvement in this user group.

Digital 3D Exoscope is Safe and Effective in Surgery for Intradural Extramedullary Tumors: A Comparative Series.

BACKGROUND: Digital 3D exoscopes have been shown to be comparably safe and effective as surgical microscopes in complex microneurosurgical procedures. However, the results of exoscopic spinal tumor surgeries are scarce. The purpose of this study is to compare results of a transition from microscope to exoscope in surgeries for spinal intradural extramedullary tumors. METHODS: We included all consecutive patients with intradural extramedullary spinal tumors operated on by the senior author during January 2016 to October 2023. The 3D exoscope was used in the latter half of the series from November 2020. We evaluated pre- and postoperative clinical findings, imaging studies, intra- and postoperative events, and analyzed surgical videos from the operations retrospectively. RESULTS: We operated 35 patients (exoscope n = 19, microscope n = 16) for intradural extramedullary tumors (meningioma n = 18, schwannoma n = 12, other n = 5). Tumors in the cervical and thoracic spine were more common than in the lumbar region. The duration of surgery was slightly longer (median 220 vs. 185 minutes) in the exoscope group. However, the rate of gross total resection of the tumor was higher (81% vs. 67%) and the tumors more often located anteriorly to the spinal cord (42% vs. 13%) in the exoscope group. No major complications (i.e., permanent motor deficit or postoperative hematoma) occurred in either group. We saw postoperative gait improvement in 81% and 85% of the patients with preoperative deterioration of gait after exoscopic and microscopic surgeries, respectively. CONCLUSIONS: This study demonstrates that exoscope-assisted surgery for spinal intradural extramedullary tumors is comparable in safety and effectiveness to traditional microscopic surgery.

Elective Cardiac Procedure Patients Have Low Preoperative Cardiorespiratory Fitness.

Preoperative cardiorespiratory fitness may influence the recovery after cardiac procedure. The aim of this study was to investigate the cardiorespiratory fitness of patients scheduled for elective cardiac procedures, using a six-minute walk test, and compare the results with a population-based sample of Finnish adults. Patients (n=234) awaiting percutaneous coronary intervention or coronary angiography, coronary artery bypass grafting, aortic valve replacement or mitral valve surgery performed the six-minute walk test. VO2max was calculated based on the walk test. The patients were compared to a population-based sample of 60-69-year-old Finnish adults from the FinFit2017 study. The mean six-minute walk test distances (meters) and VO2max (ml/kg/min) of the patient groups were: 452±73 and 24.3±6.9 (coronary artery bypass grafting), 499±84 and 27.6±7.2 (aortic valve replacement), 496±85 and 27.4±7.3 (mitral valve surgery), and 519±90 and 27.3±6.9 (percutaneous coronary intervention or coronary angiography). The population-based sample had significantly greater walk test distance (623±81) and VO2max (31.7±6.1) than the four patient groups (all p-values<0.001). All patient groups had lower cardiorespiratory fitness than the reference population of 60-69-year-old Finnish adults. Particularly the coronary artery bypass grafting group had a low cardiorespiratory fitness, and therefore might be prone to complications and challenging rehabilitation after the operation.

Small amount of alcohol did not deteriorate microsurgical dexterity: a prospective laboratory study.

BACKGROUND: Alcohol consumption has been reported to deteriorate surgical performance both immediately after consumption as well as on the next day. We studied the early effects of alcohol consumption on microsurgical manual dexterity in a laboratory setting. METHOD: Six neurosurgeons or neurosurgical residents (all male) performed micro- and macro suturing tasks after consuming variable amounts of alcohol. Each participant drank 0-4 doses of alcohol (14 g ethanol). After a delay of 60-157 min, he performed a macrosurgical and microsurgical task (with a surgical microscope). The tasks consisted of cutting and re-attaching a circular latex flap (diameter: 50 mm macrosuturing, 4 mm microsuturing) with eight interrupted sutures (4-0 multifilament macrosutures, 9-0 monofilament microsutures). We measured the time required to complete the sutures, and the amplitude and the frequency of physiological tremor during the suturing. In addition, we used a four-point ordinal scale to rank the quality of the sutures for each task. Each participant repeated the tasks several times on separate days varying the pre-task alcohol consumption (including one sober task at the end of the data collection). RESULTS: A total of 93 surgical tasks (47 macrosurgical, 46 microsurgical) were performed. The fastest microsurgical suturing (median 11 min 49 s, [interquartile range (IQR) 654 to 761 s]) was recorded after three doses of alcohol (median blood alcohol level 0.32‰). The slowest microsurgical suturing (median 15 min 19 s, [IQR 666 to 1121 s]) was observed after one dose (median blood alcohol level 0‰). The quality of sutures was the worst (mean 0.70 [standard deviation (SD) 0.48] quality points lost) after three doses of alcohol and the best (mean 0.33 [SD 0.52] quality points lost) after four doses (median blood alcohol level 0.44‰). CONCLUSIONS: Consuming small amount of alcohol did not deteriorate microsurgical performance in our study. An observed reduction in physiological tremor may partially explain this.

Objectively measured preoperative physical activity and sedentary behaviour among Finnish patients scheduled for elective cardiac procedures: baseline results from randomized controlled trial.

BACKGROUND: We investigated preoperative physical activity (PA) and sedentary behaviour (SB) in patients scheduled for elective cardiac procedures and compared them with population-based sample of Finnish adults. METHODS: Cardiac patients (n = 139) undergoing cardiac operations carried a triaxial accelerometer for seven days during the month before the procedure. Patients were categorised into four groups according to the procedure: percutaneous coronary intervention or coronary angiography (PCI-CA), coronary artery bypass grafting (CABG), aortic valve replacement (AVR) and mitral valve surgery (MVS). The raw accelerometer data was analyzed with dedicated algorithms to determine metabolic equivalents (METs, 3.5 mL/kg/min of oxygen consumption) of PA. The intensity of PA was divided into two categories: light (LPA, 1.5-2.9 METs) and moderate-to-vigorous (MVPA, ≥ 3.0 METs), while SB represented intensity < 1.5 MET without movements. SB and PA were described as daily means and accumulation from different bout lengths. Daily standing, steps and mean and peak MET-values were calculated. The results were compared between the patient groups and against the reference group from a population-based study FinFit2017. RESULTS: Cardiac patients had fewer daily steps than the FinFit population (p = 0.01), and less SB accumulating from < 20 min bouts (p = 0.002) but more from 20 to 60 min bouts (p = 0.002). Particularly, CABG group had less daily MVPA (p = 0.002) and MVPA accumulating from > 10 min bouts (p < 0.001) than the FinFit population. CONCLUSIONS: We found large differences in PA and SB between the patient groups and the FitFit population, CABG group having the worst activity profile. Also, the variation within the patient groups was wide, which should be considered to individualise the rehabilitation programs postoperatively. Trial registration clinicaltrials.gov (NCT03470246). Registered 19 March 2018, https://clinicaltrials.gov/ct2/show/NCT03470246.

Recovery Potential of Spinal Meningioma Patients With Preoperative Loss of Walking Ability Following Surgery - A Retrospective Single-Center Study.

OBJECTIVE: Spinal meningiomas are neurosurgical rarities that manifest with progressive paraor tetraparesis. The effect of timing of surgery on the recovery after the loss of walking ability is poorly known. We studied the effect of timing of surgery on restoring walking ability in surgically-treated spinal meningioma patients. METHODS: Using electronic health records, we retrospectively identified ≥ 18-year-old patients operated on during 2010-2020. The patients were followed until 30th September 2020, death or emigration. RESULTS: We identified 108 patients (81% women) with operated spinal meningiomas. The mean age of the patients was 64 years (range, 18-94 years). A gross total resection was achieved in 101 (94%), and 21 patients (19%) suffered from perioperative complications. Of the 108 patients operated on, 49 (45%) could not walk without assistance prior to surgery. At the time of first postoperative visit (mean, 3.1 months; range, 1.3-13.1 months), 14 out of 24 patients (58%) operated on within 29 days and 8 out of 20 patients (40%) operated on later than 29 days since the loss of walking ability without assistance, were able to walk without assistance. Also, 3 out of 5 paraplegic patients who underwent surgery later than 29 days after they lost the walking ability, were able to at least walk with assistance at first postoperative visit. CONCLUSION: Early surgical treatment following the loss of walking ability restores walking ability in a substantial number of patients. However, even late surgery may restore walking ability.

Physical activity and sedentary behaviour in secondary prevention of coronary artery disease: A review.

Comprehensive management of coronary artery disease (CAD) includes physical exercise as a part of daily lifestyle therapy. Still CAD patients generally have low physical activity (PA) and high sedentary behaviour (SB). This review summarizes the effect of exercise training and habitual PA and SB on physical fitness and quality of life (QoL) as well as on rehospitalizations and mortality in patients with stable CAD, recent acute coronary syndrome (ACS) or recent revascularization. A literature review of the influence of exercise, and PA and SB profiles in secondary prevention of CAD was performed using PubMed. All articles published between January 2001 and April 2019, meeting the inclusion criteria were considered. A total of 25 cross-sectional or prospective studies or randomized controlled trials (RCT) were included to this review. Exercise training was found to improve maximal oxygen consumption, QoL, and to reduce rehospitalizations and mortality among patients with established CAD. Remote PA interventions have not been as effective as the supervised exercise sessions in reducing the clinical endpoints. High SB, especially when combined to low PA, is associated with poor cardiorespiratory fitness and worse long-term prognosis among patients with ACS. In conclusion, exercise training and high PA are beneficial for patients with stable CAD, recent ACS or recent revascularization. High SB is associated with poor cardiopulmonary fitness and increased mortality in ACS patients. Novel tools using online applications and smart devices are promising means to offer remote guidance for PA among patients unable to participate in regular exercise sessions.

Two out of three of octogenarians benefitted from delayed resection of spinal meningiomas.

BACKGROUND: Can elderly patients with thoracic meningioma and severe paraparesis benefit from delayed surgery? CASE DESCRIPTION: Two out of three octogenarians with severe preoperative paraparesis (all wheelchair-bound) were able to walk again following delayed (60-120 days from onset of deficit) surgical resection of thoracic spinal meningiomas. CONCLUSION: Two out of three octogenarians with thoracic meningiomas causing severe paraparesis benefitted from the delayed (i.e. from 60 to 289 days) surgical resection of their tumors.

Personalised eHealth intervention to increase physical activity and reduce sedentary behaviour in rehabilitation after cardiac operations: study protocol for the PACO randomised controlled trial (NCT03470246).

INTRODUCTION: Personalized intervention to increase physical Activity and reduce sedentary behaviour in rehabilitation after Cardiac Operations (PACO) is a smartphone-based and accelerometer-based eHealth intervention to increase physical activity (PA) and reduce sedentary behaviour (SB) among patients recovering from cardiac surgery. DESIGN: Prospective randomised controlled trial. METHODS AND ANALYSIS: The present protocol describes a randomised controlled clinical trial to be conducted in the Heart Centres of Kuopio and Turku university hospitals. The trial comprises 540 patients scheduled for elective coronary artery bypass grafting, aortic valve replacement or mitral valve repair. The patients will be randomised into two groups. The control group will receive standard postsurgical rehabilitation guidance. The eHealth intervention group will be given the same guidance together with personalised PA guidance during 90 days after discharge. These patients will receive personalised daily goals to increase PA and reduce SB via the ExSedapplication. Triaxial accelerometers will be exploited to record patients' daily accumulated PA and SB, and transmit them to the application. Using the accelerometer data, the application will provide online guidance to the patients and feedback of accomplishing their activity goals. The data will also be transmitted to the cloud, where a physiotherapist can monitor individual activity profiles and customise the subsequent PA and SB goals online. The postoperative improvement in patients' step count, PA, exercise capacity, quality of sleep, laboratory markers, transthoracic echocardiography (TTE) parameters and quality of life, and reduction in SB and incidence of major cardiac events are investigated as outcomes. CONCLUSIONS: The PACO intervention aims to build a personalised eHealth tool for the online tutoring of cardiac surgery patients. TRIAL REGISTRATION NUMBER: NCT03470246.

Subjects with cardiovascular disease or high disease risk are more sedentary and less active than their healthy peers.

OBJECTIVES: We investigated differences in objectively measured sedentary behaviour (SB) and physical activity (PA) levels in subjects with cardiovascular disease (CVD) diagnosis or high CVD risk compared with healthy controls. METHODS: The present study includes a subsample (n=1398, Health 2011 Study) of participants, who attended health examinations and wore a triaxial accelerometer (≥4 days). Patients with CVD were identified and CVD risk was calculated for others using Framingham Risk Score (FRS). Participants were categorised into groups: FRS<10%; FRS=10%-30%; FRS>30%/CVD. Raw acceleration data were analysed with mean amplitude deviation (MAD) and angle for posture estimation (APE). MAD corresponding to intensity of PA was converted to metabolic equivalents (MET) and categorised to light (1.5-2.9 METs) and moderate to vigorous PA (MVPA≥3.0 METs). APE recognises SB and standing. RESULTS: Daily accumulated time of >30 s MVPA bouts was higher in FRS<10% group (46 min) than in FRS>30%/CVD group (29 min) (p<0.001). FRS>30%/CVD group were more sedentary, their mean daily number of >10 min SB bouts (13.2) was higher than in FRS <10% group (11.5) (p=0.002). CONCLUSION: Number and accumulated times of SB and PA bouts differed between the CVD risk groups. Causative research is required to assess the importance of SB and PA in prevention and rehabilitation of CVDs.

Association of objectively measured sedentary behaviour and physical activity with cardiovascular disease risk.

Background We evaluated the association of accelerometer-based sedentary behaviour and physical activity with the risk of cardiovascular disease. Design The design of this study used a population-based, cross-sectional sample. Methods A subsample of participants in the Health 2011 Study in Finland used the tri-axial accelerometer (≥4 days, >10 h/day, n = 1398). Sedentary behaviour (sitting, lying) and standing still in six-second epochs were recognised from raw acceleration data based on intensity and device orientation. The intensity of physical activity was calculated as one-minute moving averages of mean amplitude deviation of resultant acceleration and converted to metabolic equivalents. Metabolic equivalents were categorised to light physical activity (1.5-2.9 metabolic equivalents) and moderate-to-vigorous physical activity (moderate-to-vigorous physical activity≥3.0 metabolic equivalents). Daily sedentary behaviour, standing still, light physical activity and moderate-to-vigorous physical activity were expressed as mean daily total time, accumulated time and number of different bouts (from 30 s to >30 min), mean daily metabolic equivalent and weekly peak metabolic equivalent levels of different bout lengths and number of breaks in sedentary behaviour. The ten-year cardiovascular disease risk was based on the Framingham risk model. Results The mean number of daily sedentary behaviour bouts was more strongly associated with cardiovascular disease risk than mean daily total time. In the best model, smaller waist circumference, greater value of mean daily metabolic equivalent levels of one-minute bouts, higher accumulated time of moderate-to-vigorous physical activity lasting ≤30 min, higher number of >5 min standing bouts and a higher number of long (>30 min) bouts of light physical activity were significantly associated with lower cardiovascular disease risk (R2 = 0.836). Conclusions The objectively measured number and accumulated time from different bout lengths of physical activity and sedentary behaviour were associated with cardiovascular disease risk, which is considered relevant for estimating cardiovascular diseases and for devising preventive actions.