Innovations in craniovertebral junction training: harnessing the power of mixed reality and head-mounted displays.

OBJECTIVE: The objective of this study was to analyze the potential and convenience of using mixed reality as a teaching tool for craniovertebral junction (CVJ) anomaly pathoanatomy. METHODS: CT and CT angiography images of 2 patients with CVJ anomalies were used to construct mixed reality models in the HoloMedicine application on the HoloLens 2 headset, resulting in four viewing stations. Twenty-two participants were randomly allocated into two groups, with each participant rotating through all stations for 90 seconds, each in a different order based on their group. At every station, objective questions evaluating the understanding of CVJ pathoanatomy were answered. At the end, subjective opinion on the user experience of mixed reality was provided using a 5-point Likert scale. The objective performance of the two viewing modes was compared, and a correlation between performance and participant experience was sought. Subjective feedback was compiled and correlated with experience. RESULTS: In both groups, there was a significant improvement in median (interquartile range [IQR]) objective performance with mixed reality compared with DICOM: 1) group A: case 1, median 6 (IQR 6-7) versus 5 (IQR 3-6), p = 0.009; case 2, median 6 (IQR 6-7) versus 5 (IQR 3-6), p = 0.02; 2) group B: case 1, median 6 (IQR 5-7) versus 4 (IQR 2-5), p = 0.04; case 2, median 6 (IQR 6-7) versus 5 (IQR 3-7), p = 0.03. There was significantly higher improvement in less experienced participants in both groups for both cases: 1) group A: case 1, r = -0.8665, p = 0.0005; case 2, r = -0.8002, p = 0.03; 2) group B: case 1, r = -0.6977, p = 0.01; case 2, r = -0.7417, p = 0.009. Subjectively, mixed reality was easy to use, with less disorientation due to the visible background, and it was believed to be a useful teaching tool. CONCLUSIONS: Mixed reality is an effective teaching tool for CVJ pathoanatomy, particularly for young neurosurgeons and trainees. The versatility of mixed reality and the intuitiveness of the user experience offer many potential applications, including training, intraoperative guidance, patient counseling, and individualized medicine; consequently, mixed reality has the potential to transform neurosurgery.

Mission impossible: chemotherapy in the intensive care for pineal region germ cell tumor.

Pineal region tumors are rare and a heterogenous group of primary central nervous system tumors which are primarily classified as germ cell tumors and non-germ cell tumors. Chemotherapy and radiotherapy as the primary treatment modalities have been reported to result in good outcomes. We discuss the case of a young girl who presented to our emergency department in an unconscious state and had a large lesion in the posterior third ventricular region, but without any associated hydrocephalus which could explain her stuporous state. Given the rapid decline in her sensorium, we were faced with the difficult choice between surgical decompression of the tumor and a trial of rescue chemotherapy following histopathological confirmation through biopsy. She underwent an open biopsy followed by chemotherapy in a neurosurgical intensive care unit despite her poor Karnofsky performance score. She improved after chemotherapy and her tumor decreased in size significantly over time. We highlight the role of chemotherapy administered in the neurosurgical ICU to an unconscious patient with a large chemoresponsive tumor leading to rapid shrinkage of the lesion and gradual improvement in the sensorium of the patient.

Challenges and prospects of neurosurgical teleconsultations in a developing country: a reality check.

OBJECTIVE: The adoption of telemedicine became a necessity during the COVID-19 pandemic because patients found commuting to be difficult owing to travel restrictions. Initially, audio-based teleconsultations were provided. Later, on the basis of the feedback of patients and caregivers, the authors started to provide video-based teleconsultations via WhatsApp. The authors subsequently surveyed the patients and caregivers to determine their satisfaction levels with telemedicine services. METHODS: An anonymized telephone survey of patients who had participated in teleconsultation was conducted with a structured questionnaire. The responses were analyzed and their correlations with the perceived benefits and limitations of audio and video teleconsultation were determined. RESULTS: Three hundred respondents were included in the first round of surveys, of whom 250 (83.3%) consented to video teleconsultation. Among the respondents who participated in both audio and video teleconsultations (n = 250), paired analysis showed that video teleconsultation was perceived as better in terms of providing easier access to healthcare services (p < 0.001), saving time (p < 0.001), and satisfaction with the way patient needs were conveyed to healthcare providers (p = 0.023), as well as in terms of adequacy of addressing healthcare needs (p < 0.001) and consequently providing a higher rate of overall satisfaction (p < 0.001). For both audio and video teleconsultation, overall patient satisfaction was significantly related to only previous exposure to WhatsApp. However, for video consultation, longer call duration (p = 0.023) was an important independent factor. Video teleconsultation was preferable to face-to-face consultation irrespective of educational status, but higher education was associated with preference for video teleconsultation. CONCLUSIONS: Both audio and video teleconsultation are viable cost-effective surrogates for in-person physical neurosurgical consultation. Although audio teleconsultation is more user-friendly and is not restricted by educational status, video teleconsultation trumps the former owing to a more efficient and satisfactory doctor-to-patient interface.

Posterior fixation for paediatric and adolescent unstable hangman's fracture: evolution to C1 sparing techniques.

PURPOSE: The aim was to study surgical outcomes in hangman's fractures in paediatric and adolescent patients and to demonstrate evolution in posterior surgery from C1-C2-C3 fusion to C1 sparing techniques. METHODS: Patients (aged ≤ 18 years) operated at a tertiary level centre between September 2011 to February 2018 with more than 1 year of follow-up were included. Neurological status, type of fracture, operating time, blood loss, follow-up, and complications were assessed. RESULTS: Nine patients were included, with mean age mean of 16.45 years, with a mean follow-up of 42.78 months. Six patients having neurological deficit showed improvement. Two patients, one having undergone C1-C3 lateral mass screw rod fixation (LMSF) and other had C2 pedicle screw with C3 LMSF, developed kyphosis for which fixation was further extended caudally. One patient with an old hangman's fracture with reabsorbed axis pedicle underwent C2 body screw along with C3-C4 pedicle screw rod fixation and C2 pedicle reconstruction. All patients showed evidence of postoperative fusion. CONCLUSION: Hangman's fractures in young patients can be successfully managed via posterior fixation. In our centre, we have evolved in the direction of motion preservation at C1 C2 joint, along with 3 column stable fixation of the C2 pedicle. C2 pedicle reformation has allowed motion preserving surgery in complex fracture types. Extension of construct till C4 in selected cases is important to prevent postoperative kyphosis.

Impact of various cervical surgical interventions in patients with Hirayama's disease-a narrative review and meta-analysis.

Hirayama disease (HD) is a relatively uncommon cause of lower cervical myelopathy. A number of surgical approaches have been described in patients with HD in literature. We reviewed the literature and did a systematic review and meta-analysis of the studies which presented the clinical outcome following surgical intervention in HD. A systematic search of literature was performed with the keywords "Surgical treatment in Hirayama Disease", "Surgical approach in Hirayama Disease" and "Hirayama disease surgery". Data related to clinical outcome following surgery was pooled to calculate the pooled proportion of clinical improvement following anterior and posterior surgical approach. Thirty-four articles met the inclusion criteria and were included in the final review. Altogether, there were 10 types of surgical procedures performed for Hirayama disease. The most commonly described surgical technique was anterior cervical discectomy and fusion with cervical plating. The pooled proportion of patients experiencing clinical improvement following all cervical approaches was 80% (95% confidence interval 76 to 84%). Pooled proportion was maximum for anterior cervical plating (96% (95% confidence interval 62 to 100%)) and minimum for ACDF without plating (57% (95% confidence interval 20 to 88%)). Subgroup analysis based on different surgical approaches was not significant (p value = 0.61). The pooled proportion of patients experiencing clinical improvement following anterior and posterior cervical approach was 80% (95% confidence interval 76 to 84%) and 81% (95% confidence interval 66 to 91%). The indications of surgical treatment in patients with HD include poor patient compliance for neck collar or rapidly progressing severe disease. Good results with more than 80% chances of clinical improvement have been reported following various anterior and posterior surgical approaches. However, there was no significant difference in the pooled outcome of different surgical approaches. Most common technique used in literature is anterior cervical discectomy and fusion with plating.

Impact of different visualization devices on accuracy, efficiency, and dexterity in neurosurgery: a laboratory investigation.

OBJECTIVE: Extracorporeal telescopes (exoscopes) have been the latest addition to the neurosurgeons' armamentarium, acting as a bridge between operating microscopes and endoscopes. However, to the authors' knowledge there are no published preclinical laboratory studies of the accuracy, efficiency, and dexterity of neurosurgical training for the use of 2D or 3D exoscopes compared with microscopes. METHODS: In a controlled experimental setup, 22 participating neurosurgery residents performed simple (2D) and complex (3D) motor tasks with three visualization tools in alternating sequence: a 2D exoscope, 3D exoscope, and microscope, using a block randomization model based on the neurosurgeons' prior training experience (novice, intermediate, and senior: n = 6, 12, and 4, respectively). Performance scores (PS; including error and efficiency scores) and dexterity scores (DS) were calculated to objectify the accuracy, efficiency, and finesse of task performance. Repeated measures ANOVA analysis was used to compare the PS, DS, and cumulative scores (CS) of candidates using the three visualization aids. Bland-Altman plots and intraclass correlation coefficients were generated to quantify intraobserver and interobserver agreement for DS. Subgroup analysis was performed to assess the impact of participants' prior training. A postexercise survey was conducted to assess the comfort level (on a 10-point analog scale) of the participants while using each visualization tool for performing the suturing task. RESULTS: PS, DS, and CS were significantly impacted by the visualization tool utilized for 2D motor tasks (p < 0.001 for each), with the microscope faring better than the 2D exoscope (p = 0.04) or 3D exoscope (p = 0.008). The PS for the 3D object transfer task was significantly influenced by the visualization aid used (p = 0.007), with the microscope and 3D exoscope faring better than the 2D exoscope (p = 0.04 for both). The visualization instrument used significantly affected the DS and CS for the suturing task (p < 0.001 for both), with the microscope again scoring better than the 2D exoscope (p < 0.001) or 3D exoscope (p = 0.005). The impact of the visualization aid was more apparent in participants with a shorter duration of residency (novice, p = 0.03; intermediate, p = 0.0004). Participants also felt the greatest operational comfort while working with a microscope, 3D exoscope, and 2D exoscope, in that order (p < 0.0001). CONCLUSIONS: Compared with 3D and 2D exoscopes, an operating microscope provides better dexterity and performance and a greater operational comfort level for neurosurgeons while they are performing 2D or 3D motor tasks. For performing complex 3D motor tasks, 3D exoscopes offer selective advantages in dexterity, performance, and operational comfort level over 2D exoscopes. The relative impact of visualization aids on surgical proficiency gradually weakens as the participants' residency duration increases.

Residency perception survey among neurosurgery residents in lower-middle-income countries: grassroots evaluation of neurosurgery education.

OBJECTIVE: The evolution of the neurosurgical specialty in lower-middle-income countries is uniformly a narrative of continuous struggle for recognition and resource allocation. Therefore, it is not surprising that neurosurgical education and residency training in these countries is relatively nascent. Dr. Harvey Cushing in 1901 declared that he would specialize in neurosurgery and gave his greatest contribution to the advancement of neurosurgical education by laying the foundations of a structured residency training program. Similar efforts in lower-middle-income countries have been impeded by economic instability and the lack of well-established medical education paradigms. The authors sought to evaluate the residency programs in these nations by conducting a survey among the biggest stakeholders in these educational programs: the neurosurgical residents. METHODS: A questionnaire addressing various aspects of the residency program from a resident's perspective was prepared with Google Forms and circulated among neurosurgery residents through social media and email groups. Where applicable, a 5-point Likert scale was used to grade the responses to the questions. Responses were collected from May to October 2019 and analyzed using descriptive statistics. Complete anonymity of the respondents was ensured to keep the responses unbiased. RESULTS: A total of 195 responses were received, with 189 of them from lower-middle-income countries (LMICs). The majority of these were from India (75%), followed by Brazil and Pakistan. An abiding concern among residents was lack of work hour regulations, inadequate exposure to emerging subspecialties, and the need for better hands-on training (> 60% each). Of the training institutions represented, 89% were offering more than 500 major neurosurgical surgeries per year, and 40% of the respondents never got exposure to any subspecialty. The popularity of electronic learning resources was discernible and most residents seemed to be satisfied with the existent system of evaluation. Significant differences (p < 0.05) among responses from India compared with those from other countries were found in terms of work hour regulations and subspecialty exposure. CONCLUSIONS: It is prudent that concerned authorities in LMICs recognize and address the deficiencies perceived by neurosurgery residents in their training programs. A determined effort in this direction would be endorsed and assisted by a host of international neurosurgical societies when it is felt that domestic resources may not be adequate. Quality control and close scrutiny of training programs should ensure that the interests of neurosurgical trainees are best served.

Craniovertebral junction evaluation by computed tomography in asymptomatic individuals in the Indian population.

BACKGROUND: The available literature on the anatomy and imaging of the craniovertebral junction (CVJ) focusses on the osteometric indices described for the detection of abnormal relationships between the components of CVJ. However, a knowledge of the normal osteometry of this region in the Indian population is critically important for the operating surgeon as it may influence the surgical technique as well as the choice, size and configurations of the implants. It is also important to determine whether critical differences exist between the osteometric data of Indians and the rest of the world for this part of the anatomy. Accordingly, the present study is an attempt to quantitate the osteometric indices for the anatomically normal CVJ in Indian subjects. MATERIALS AND METHODS: We retrospectively studied the imaging data of 49 consecutive adult patients (31 males, 18 females) who underwent a computed tomographic (CT) angiogram for suspected vascular conditions unrelated to the craniovertebral junction. Several parameters related to the atlanto-dental relationship, foramen magnum, atlas and axis vertebrae were recorded, including the dimensions of the commonly instrumented bony regions and also the indices related to the CVJ bony relationships. The data was also compared between the two genders, statistically through the Student's t-test using the statistical program "R". RESULTS: No patient had an atlanto dens interval >2.5 mm. The mean distance of the odontoid tip from the McRae line in this series was 5.11 mm and no patient had the odontoid tip above the McRae line. Female subjects had significantly smaller diameters of C1 lateral masses and odontoid screw trajectory length when compared to males. Additionally, in the Indian population, the length range of odontoid screw trajectory and the thickness of the narrowest part of the C2 pedicles was smaller with respect to similar data from other geographical regions. However, the rest of the parameters resembled the data from studies conducted on populations with other ethnicities. CONCLUSION: The osteometric parameters of the CVJ in the Indian population are largely similar to those described globally. However, there are some important differences too which can influence the design of surgical implants suited to the Indian population.

Standardization of the technique of silicon injection of human cadaveric heads for opacification of cerebral vasculature in Indian conditions.

A surgeon's understanding of the surgical anatomy can be greatly enhanced by the dissection of preserved cadaveric specimens. A reliable and inexpensive biological model for testing and standardization of dye injection concentrations is proposed utilizing the goat's head as a biological model. The first phase was concerned with standardization of the dye by titrating its concentration and injecting various amounts into cerebral vessels of a goat's head until an optimal concentration had been ascertained. In the second phase, this optimum concentration of the dye was injected into four human cadaveric heads following the same technique standardized using the goat's head. Upon dissecting the four cadaveric human heads which were injected with silicon dyes and preserved in 10% formalin, the vessels were all well-opacified and the brain was of near normal consistency and good for dissection, without showing any features of putrefaction. The goat model, having similar color, texture, and the handling as the cadaveric head, offers an opportunity to test indigenously manufactured polymerizing dyes in the future. This biological model, therefore, has the potential to considerably reduce the cost of cadaver preparation.

Reshaping the zygomatic complex: A "small step" in frontotemporal craniotomy and a "big leap" in exposure.

CONTEXT: Pterional or fronto-temporal craniotomy, developed by Prof. M. G. Yasargil, is among the most familiar skull base surgery techniques. The cranio-orbito zygomatic (COZ) approach evolved to address the significant limitations of the pterional exposure in excising some parasellar lesions. Although extremely versatile, the COZ technique involves extensive dissection of the cranio-facial soft tissue and reconstruction towards the end of the procedure. The zygomatic reshaping is a minor modification of the pterional approach, which enhances the exposure possible through the classical approach and often circumvents the need for an orbito-zygomatic osteotomy. AIMS: To demonstrate the technique of reshaping of the zygomatic complex for an optimum surgical exposure and cosmetic results. MATERIALS AND METHODS: Between April 2013 and December 2014, 8 patients with various middle and anterior skull base lesions were operated using this technique. These patients form the clinical material for this study. The clinical details, radiological images and follow-up data of these patients were collected for this clinical series. RESULTS: No mortality or significant morbidity were noted in this series. The post-operative cosmetic results were also acceptable. CONCLUSIONS: A quick and easy modification of the classical pterional approach through zygomatic reshaping has the potential to provide a significantly enhanced surgical exposure for parasellar lesions. Using this approach, it might be possible to avoid an extensive orbito-zygomatic osteotomy in suitable lesions.

Papillary Tumors of Pineal Region: A Single-Center Experience in Management of 11 Cases.

BACKGROUND: Papillary tumors of pineal region (PTPR) comprise a very rare subset of pineal region tumors that have been recently described. Literature on the management and outcome of PTPR is scarce owing to the rarity of these tumors. To address this lacuna, we analyzed our experience in management of PTPR. METHODS: We retrospectively analyzed the outcome of 11 patients with histopathologically proven PTPR who underwent surgical excision at our center. RESULTS: Mean patient age was 33.3 years (range, 12-45 years), and male-to-female ratio was 1.75:1. Headache was the most common presentation followed by visual disturbances, altered sensorium, Perinaud syndrome, and seizures. Cerebrospinal fluid diversion was required in 6 patients. Krause approach was the most common approach used for tumor excision (9/11 cases). There was no perioperative mortality. Two patients were lost to follow-up. In the remaining 9 patients, the average follow-up period was 45 months (range, 12-79 months). On first postoperative magnetic resonance imaging, 8 patients showed no evidence of residual tumor (gross total resection), while 1 patient had small residual tumor (near-total resection) that remained stable during follow-up. Four patients underwent adjuvant chemoradiotherapy. None of the patients developed recurrence during follow-up. CONCLUSIONS: PTPR are a rare subgroup of pineal region tumors with distinct cells of origin but presentation similar to other pineal region tumors. Surgical resection constitutes the mainstay of management, and the extent of resection appears to be the most important determinant of prognosis. The role of adjuvant therapy still needs to be determined.

Neurosurgery as a Top-Drawer Choice for Residency in India: Reality or Myth?

INTRODUCTION: This survey was conducted to explore the perceptions of undergraduate (UG) medical students regarding enrolling in a neurosurgical training program. The purpose was to understand' expectations, reasons, apprehensions, and variables influencing students' decisions to pursue a career in neurosurgery. The results shed light on students' perceptions and can help educational institutions and training programs draw in and encourage aspiring neurosurgeons. METHODS: A 35-point online questionnaire was created using Google Forms (Google LLC) after content and face validation and circulated using social media platforms among various public medical colleges across India. Responses were collected over a period of 3 months, from February 2023 to April 2023. A 5-point Likert scale was used to collect the responses wherever applicable. RESULTS: A total of 1042 respondents from 47 medical colleges completed the survey. The majority of the students were not exposed to neurosurgery during their UG program, but despite this, 60.1% (n = 627) were willing to consider it as their career option. Around 91.4% of the respondents perceived neurosurgery to be a challenging but prestigious specialty that has a long learning curve and the worst work-life balance when compared with other specialties. The majority of the respondents (strongly disagree = 24.3%, n = 253; disagree = 31.7%, n = 330) did not view neurosurgery as a male-dominated specialty. Most students preferred a 6-year training program over a 3-year program (P = 0.001) if their medical college had such a course. CONCLUSIONS: Our study reveals that although a majority of the UG students would like to join neurosurgery residency, there are significant barriers in the form of less exposure, negative perceptions, and apprehensions toward the branch. Enhancing medical students' awareness about neurosurgery necessitates the integration of hands-on workshops, simulation-based training, didactic lectures, and neurosurgery rotations into the UG curriculum.

Beyond Traditional Training: Exploring the Benefits of Virtual Reality Simulator in Lumbar Pedicle Screw Insertion - A Randomized Controlled Trial.

INTRODUCTION: This study compares the effectiveness of virtual reality simulators (VRS) and a saw bone model for learning lumbar pedicle screw insertion (LPSI) in neurosurgery. METHODS: A single-center, cross-sectional, randomized controlled laboratory investigation was conducted involving residents and fellows from a tertiary care referral hospital. Participants were divided into two groups (A and B). Group A performed 3 LPSI tasks: the first on a saw bone model, the second on VRS, and the third on another saw bone model. Group B completed 2 LPSI tasks: the first on a saw bone model and the second on another saw bone model. The accuracy of LPSI was evaluated through noncontrast computed tomography scans for the saw bone models, while the in-built application of VRS was utilized to check for accuracy of screw placement using the simulator. RESULTS: The study included 38 participants (19 in each group). Group A participants showed reduced mean entry point error (0.11 mm, P 0.024), increased mean purchase length (4.66 cm, P 0.007), and no cortical breaches (P 0.031) when placing the second saw bone model screw. Similar improvements were observed among group A participants in PGY 1-3 while placing the second saw bone model screws. CONCLUSIONS: Virtual reality simulators (VRS) prove to be an invaluable tool for teaching complex neurosurgical skills, such as LPSI, to trainees. This technology investment can enhance the learning curve while maintaining patient safety.

Impact of penicillin allergy records on antimicrobial prescribing in hospitalised patients.

BACKGROUND: The overdiagnosis of penicillin allergy and misclassification of non-truly allergic reactions is a growing public health problem, associated with the overuse of broad-spectrum and restricted antimicrobials. We aimed to evaluate the impact of penicillin allergy status on antimicrobial prescribing. METHODS: A retrospective study of inpatients with a documented penicillin allergy receiving antimicrobials was conducted from 1 April to 1 July 2021. Antimicrobial prescribing and clinical characteristics were compared between patients with an active penicillin allergy label and those whose label was removed following antimicrobial stewardship team review. Antimicrobials were classified in two categories: i) 'Access' (recommended), ii) 'Watch and Reserve' (restricted) according to WHO AWaRe classification, a tool to guide appropriate antibiotic use. RESULTS: 437 patients with a documented penicillin allergy receiving antimicrobials were included. 353 patients with an active penicillin allergy label, more frequently received antimicrobials from the 'Watch and Reserve list' (283;80% vs 30;37%; p<0.001). In contrast, 84 patients who were de-labelled received more often antimicrobials from the 'Access list' (53;63% vs 64;18%; p<0.001). CONCLUSIONS: Penicillin allergy reviews and de-labelling strategies may reduce the use of restricted antimicrobials under the 'Watch and Reserve list'. This practice should be encouraged and reinforced in all hospitals.

Impact of green finance and fintech on sustainable economic growth: Empirical evidence from India.

This research study analytically investigates the influence of green finance and financial technology on sustainable economic growth. The analysis is based on data from Indian states from 2010 to 2021. The research paper uses the panel regression method to examine the association between fintech, green finance and economic growth by applying a two-step GMM (generalized model of moments) to determine the endogeneity issues of the variables. This paper reveals that green finance widely helps quality economic growth by significantly impacting finance structure, financial effectiveness, and environmental quality protection development. Furthermore, fintech enhances the significant effect of green finance in the finance structure and environmental quality protection while lacking consequences on the association between green finance and economic effectiveness. Based on the results, the current research paper offers policy submissions for policymakers and the Government of India, including strengthening the consolidation of fintech growth with green finance, structuring a quality environmental revelation outline to control state governments in refining the effectiveness of green finance, and emerging prolonged satisfactory protocol as an outside involvement proceeding to encourage green finance in the non-public sector.

Looking Beyond the Anterolateral Skull Base with Frontotemporal Dural Fold Unlocking and Extradural Clinoidectomy: A Series of 17 Cases Deciphering the Translation from a Cadaver to Real, and Real to Pathologically Distorted Anatomy.

Objective: This article aims to discuss the surgical nuances and major adjustments necessary in unlocking the frontotemporal dural fold (FTDF) and extradural anterior clinoidectomy (EDAC) in actual cases, allowing translation from the cadaveric to a clinical scenario. Materials and Methods: We retrospectively reviewed the technical details of 17 procedures over 8 years, where both the initial steps (FTDF unlocking and EDAC) were performed. Lesions involving or extending to the anterolateral skull base, like the suprasellar cistern, optico-carotid cistern, interpeduncular cistern, petrous apex, and cavernous sinus, were included. The clinical data of the patients were retrieved retrospectively from the hospital information system (HIS) and in-patient records. This study was approved as a multicenter individual project with IEC No: 2020-342-IP-EXP-34. Results: An illustrated note of the common steps and outcome of the 17 procedures of unlocking the FTDF and EDAC done is presented. The technique provided adequate exposure in performing aneurysmal clipping (posterior communicating artery [P. com], basilar top, and superior hypophyseal artery [SHA] aneurysm), giant pituitary adenoma (Wilson Hardy grade 4E, n = 2), fifth nerve schwannoma (n = 4), right Meckel's cave melanoma, cavernous hemangioma (n = 4), petroclival meningioma (n = 2), and clival chordoma. Temporary and permanent cranial nerve palsy as a procedure-related complication was seen in 11.8% (n = 2) each. Complete excision was achieved in 13 (n = 13/14) patients with tumors. Conclusion: FTDF unlocking and EDAC are elegant procedures providing reasonable access to the anterolateral skull base for myriad pathologies. Brain bulge, cavernous sinus bleeding, and losing the plane of dural duplication were significant challenges in switching from cadaveric to a clinical scenario.

Specific sensory neurons and insulin-like peptides modulate food type-dependent oogenesis and fertilization in Caenorhabditis elegans.

An animal's responses to environmental cues are critical for its reproductive program. Thus, a mechanism that allows the animal to sense and adjust to its environment should make for a more efficient reproductive physiology. Here, we demonstrate that in Caenorhabditis elegans specific sensory neurons influence onset of oogenesis through insulin signaling in response to food-derived cues. The chemosensory neurons ASJ modulate oogenesis onset through the insulin-like peptide (ILP) INS-6. In contrast, other sensory neurons, the olfactory neurons AWA, regulate food type-dependent differences in C. elegans fertilization rates, but not onset of oogenesis. AWA modulates fertilization rates at least partly in parallel to insulin receptor signaling, since the insulin receptor DAF-2 regulates fertilization independently of food type, which requires ILPs other than INS-6. Together our findings suggest that optimal reproduction requires the integration of diverse food-derived inputs through multiple neuronal signals acting on the C. elegans germline.

SimSpine: A Cost-Effective Spinal Endoscopy Training Prototype for Neurosurgical Residents Skills Training.

OBJECTIVE: To compare the SimSpine (indigenously developed, low-cost model) and EasyGO! (Karl Storz, Tuttlingen, Germany) systems for simulation of endoscopic discectomy. METHODS: Twelve neurosurgery residents, 6 in postgraduate years 1-4 or equivalent (junior) and 6 in postgraduate years 5-6 or equivalent (senior), were randomly allocated (1:1) to either EasyGO! or SimSpine endoscopic visualization systems for endoscopic lumbar discectomy simulation on the same physical simulator. After the first exercise, the participants switched over to the other system, and the exercise was repeated. Time taken to dock the system, time to reach annulus, time required for task completion, dural violation, and volume of disc material removed were used for calculating objective efficiency score. Subjective scoring (Neurosurgery Education and Training School [NETS] criteria) was performed by 4 blinded mentors based on recorded video on 2 separate occasions 2 weeks apart. Cumulative score was calculated based on efficiency and Neurosurgery Education and Training School scores. RESULTS: Performance metrics were similar across the 2 platforms, regardless of participant seniority (P > 0.05). Time to reach disc space and discectomy time improved for both EasyGO! (P = 0.07 and P = 0.03, respectively) and SimSpine (P = 0.01 and P = 0.04, respectively) between first and second exercises. Efficiency and cumulative scores were better (P = 0.04 and P = 0.03 respectively) when EasyGO! was used as the first device compared with SimSpine. CONCLUSIONS: SimSpine is a cost-effective viable alternative to EasyGO for endoscopic lumbar discectomy simulation-based training.