The Impact of a Robotic Digital Microscope on the Ergonomics in a Neurosurgical Operating Theatre (A Single-Centre Experience).

Ergonomics is an emerging concept in the neurosurgical operating theatre, where neurosurgeons work under great concentration and frequently neglect their uncomfortable body posture. Work-related musculoskeletal disorders (WMSD) are becoming a widespread burden in the neurosurgical community. WMSD have a negative impact on surgical performance and decrease the surgeons' quality of life. Here we present our single-centre 2-month experience with the Aesculap AEOS® Robotic Digital Microscope (RDM) and prospectively calculate the REBA (Rapid Entire Body Assessment) scores and compare them with similar neurosurgical cases operated with a conventional operative microscope (OPMI).Materials and Methods: For a period of 2 months at the Department of Neurosurgery of the University Hospital Pirogov, Sofia, Bulgaria, 41 consecutive patients were operated on using RDM. The REBA employee assessment worksheets were filled in prospectively to assess the ergonomics of the senior author (N.G.) while using the RDM and the OPMI.Results and Conclusion: The ergonomics during neurosurgical operations could be substantially improved with the implementation of the exoscope. For challenging cranial approaches, where the operator must frequently "look around corners" the exoscope has a major advantage compared with the OPMI-the REBA score is 2.6 times lower for the exoscope and reaches a low risk for WMSD. For spinal operations, the neck score as part of the REBA score is three times lower for the exoscope.

Bilateral posterior fracture - dislocation of the shoulders after epileptic seizure in patients with cerebral meningiomas. Triple E syndrome - Review of the literature.

Bilateral posterior fracture-dislocation of the shoulders is a very rare entity with an average rate of 0.6/100000 per year. It was first described in 1902 by Mynter. Only a few cases have been published so far. The "triple E syndrome" is used to describe the causative factors involved in this injury - epilepsy, electrocution, extreme trauma. We present our experience since 2019 with 2 cases of bilateral posterior fracture-dislocation of the shoulders after an epileptic seizure in patients with cranial meningiomas. Total removal of the meningiomas was performed in both cases and afterwards the patients were operated on by the traumatology team. The shoulder joint is the most commonly dislocated joint in the body with less than 4 % being posteriorly dislocated. Bilateral fracture-dislocation of the shoulders is associated with "triple E syndrome" and 90 % of the cases are related to seizures. The diagnosis is usually delayed due to the lack of signs of trauma. Early diagnosis and proper surgical treatment can maximize the final functional results and patient recovery.

Subjective workload measurement of the transition from a conventional operative microscope to a Robotic Digital Microscope. A pilot study.

•Evaluate the subjective workload for transition of an experienced neurosurgeon from a conventional operative microscope /OPMI/ to a Robotic Digital Microscope /RDM/.•Show a single center initial experience of the use an exoscope.•The exoscope improves ergonomics.•Operative exoscope could reduce work-related musculoskeletal disorders.

A rare case of posttraumatic meningitis presenting with acute hydrocephalus.

Posttraumatic meningitis is a severe complication of traumatic brain injury (TBI) that dramatically increases its mortality. Skull-base fractures increase the risk of posttraumatic meningitis. Posttraumatic hydrocephalus was encountered in 0.7 %-29 % of the patients with severe head injury. Posttraumatic hydrocephalus should be differentiated from ventriculomegaly due to brain atrophy. We present a clinical case of a 52-year-old patient after a mild TBI and a linear skull base fracture who developed acute hydrocephalus in the context of a posttraumatic meningitis within the first week after the injury. The occurrence of hydrocephalus in patients with posttraumatic meningitis is not well studied but could lead to rapid deterioration of the patient. It results from injury-induced disturbance of CSF flow either through obstruction or lack of CSF reabsorption. Factors increasing the risk of posttraumatic meningitis are - operative interventions, skull base fractures and CSF leakage. Patients with meningitis usually present with lower GCS score. The lower GCS is a harbinger of worse prognosis. Therefore, aggressive medical treatment is warranted. With this case study we show that meningitis presenting with PTH can develop rapidly over 24 h within the first week post mild head injury with basilar skull fracture. A swift response in providing timely ventricular drainage, together with an appropriate antimicrobial coverage, can greatly reduce any lasting neurological deficits and produce a good clinical outcome.

Microanatomical bases for intraoperative division of the posterior communicating artery.

BACKGROUND: Micro-anatomical parameters of the hypoplastic posterior communicating artery (PCoA) are assessed and compared with the micro-anatomical parameters of the adult type PCoA. Based on the results obtained, the safest place is proposed for PCoA division during basilar tip aneurysm surgery via the pterional route. METHODS: In 35 human cadaver brains, red coloured latex was injected and micro-anatomical dissection was performed. RESULTS: Seventy PCoA were found. Adult type PCoA was found in 29 cases (41.43%) with mean length 12.58 mm. Reduction of the PCoA diameter from its anterior to its posterior third by up to 20% was found in 27% and by more than 20% in 10% of the cases. The mean perforating vessel number was 8.17, distributed in each third: 3.48, 2.90 and 1.79, respectively. A hypoplastic PCoA was found in 33 cases (47.14%) with mean length 16.09 mm. The PCoA's diameter reduction by up to 20% was found in 24% and by more in 27% of the cases. In 6% of the cases an extreme reduction by up to 70% was observed. The mean perforating vessel (PV) number was 8.82, distributed in each third: 3.18, 3.36 and 2.27, respectively. CONCLUSIONS: Hypoplastic PCoA tends to be longer and with a more distinct diameter reduction from the anterior to the posterior third than the adult type PCoA. The PV anatomical parameters are similar for both groups. The posterior third of the PCoA seems to be the area where the risk of perforating vessel damage is the least when performing intra-operative PCoA division.