Name:
10.3171/2023.10.FOCVID23105
Description:
10.3171/2023.10.FOCVID23105
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Duration:
T00H08M12S
Embed URL:
https://stream.cadmore.media/player/ab66dfc7-7d7e-4153-9c0d-6761af750fb7
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https://cadmoreoriginalmedia.blob.core.windows.net/ab66dfc7-7d7e-4153-9c0d-6761af750fb7/17. 23-105.mp4?sv=2019-02-02&sr=c&sig=GEfJ%2BFiKv%2FLXknwYgpM1AJhpk9JFxMuijfziP1s0X0s%3D&st=2026-05-02T02%3A14%3A32Z&se=2026-05-02T04%3A19%3A32Z&sp=r
Upload Date:
2023-11-30T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SPEAKER: This presentation provides an overview of our experience in performing selective dorsal rhizotomy using a high-definition 3D exoscope system. Here are the abbreviations we have used for this presentation. Our patient was a 6-year-old male with a background of cerebral palsy with spastic diplegia. Clinically, he was GMFCS level III to IV and had a modified Ashworth Scale of 3 involving bilateral lower limbs.
SPEAKER: There was no dystonia or ataxia. Selective dorsal rhizotomy was decided as the procedure of choice after a multidisciplinary team consensus. The MDT consists of neurosurgeons, orthopedic surgeons, neurorehabilitation physicians and allied health professionals. Preoperative workup as per institutional protocol included thorough neuroimaging, physical and cognitive assessments, followed by a trial period of oral baclofen and targeted areas of botulinum toxin injections in tandem with intensive physiotherapy.
SPEAKER: As part of this workup, a progressive cerebral pathology was excluded. The aim of selective dorsal rhizotomy is to reduce spasticity while ensuring adequate tone and power is preserved for long-term motor function, especially ambulation. In the context of our case, the surgery is performed with the assistance of a high-definition 3D exoscope.
SPEAKER: We are using the Synaptive Modus V exoscope. An exoscope confers significant advantages in terms of surgical visualization and ergonomics. In recent years, there is a growing body of literature with regard to its use in neurosurgery, especially in adult spine conditions. Separately, selective dorsal rhizotomy is a procedure that may be prolonged owing to time spent on intraoperative electromyography testing of individual nerve roots in tandem with the neurorehabilitation team.
SPEAKER: This aspect of the surgery is extremely important to achieve the optimal reduction in limb spasticity. Under such circumstances, the 3D exoscope allows the neurosurgical team to operate in a more comfortable posture, and at the same time, provide excellent visualization for both the surgeons as well as the neurorehabilitation team. Nonetheless, the setup for the 3D exoscope system tends to cause crowding of operative space.
SPEAKER: This drawback becomes relevant for selective dorsal rhizotomy when manpower, operating tools, and neuromonitoring equipment needs to share limited space with the 3D exoscope setup. Therefore, strategic rationalization of space is paramount and will be subsequently discussed. Here, the neurosurgical team flanks the patient and the scrub team is placed opposite to the lead neurosurgeon. We place the anesthesia team and their equipment at the head of the operating bed, allowing the neurorehabilitation team at the opposite end to access the lower limbs freely when needed.
SPEAKER: The 3D exoscope is situated beside the lead neurosurgeon and both large screens are placed at the angle where both the lead and assistant surgeons are able to comfortably view with minimal neck movement. All present at the surgery are provided with 3D glasses to view the surgery in real time. After general anesthesia, the patient is placed in a standard prone position for lumbar spine surgery with relevant pressure areas protected.
SPEAKER: Intraoperative neurophysiological monitoring electrodes for motor evoked potentials, somatosensory evoked potentials, and electromyography are placed accordingly. Next, the patient is surgically draped in a manner that allows the neurorehabilitation team to test the lower limbs intraoperatively. After skin exposure of the lumbar spine, a standard laminotomy from L1 to S1 was performed.
SPEAKER: Surgical exposure was further optimized with Kerrison Rogers. A pointer wirelessly linked to the 3D exoscope was used to optimize visualization. Next, durotomy was performed via long midline incision. Tacking sutures are then placed. The view is oriented with the right screen being cranial, left screen being caudal, and the top being the patient's left. The nerve root bundles of the cauda equina were separated and traced back to the relevant exit foramina.
SPEAKER: Individual routes were subsequently separated further into dorsal sensory and ventral motor root components. Confirmation of their function was tested with the electromyography. Each nerve root bundle was then isolated with surgical patties. This process was meticulously repeated for each nerve root bundle.
SPEAKER: Following that, the sensory roots were then split into its rootlets. At this point, the rootlets were stimulated once more for reconfirmation prior to sectioning. During this process, the neurorehabilitation team begins to assess for the reduction of spasticity.
SPEAKER: This will be repeated for each dorsal root. As demonstrated, the 3D exoscope was able to produce superb visuals while reducing surgical fatigue of the surgeons during this long procedure. An additional advantage was that the system's pointer was able to further enhance this by guiding the exoscope into position and thus ensuring an optimal angle of view.
SPEAKER: Closure is performed in layers following the principles of previously published literature. Benefits of this system include excellent intraoperative visualization, improved ergonomics, and the reduction of musculoskeletal fatigue in a prolonged surgery. Its high magnification and illumination views offer a wide operative corridor, increased focal length range and depth, and immersive surgical experience.
SPEAKER: The drawbacks of theater crowding can be overcome with conscientious preoperative planning and coordination with the different subspecialty teams involved. Presently, the operating microscope remains the mainstay of most neurosurgical procedures, and its ease of setup has been instilled at our institution for several years. Under such circumstances, the introduction of a 3D surgical exoscope, with its different setup, requires a trial period for the surgical team to overcome learning curves.
SPEAKER: At the time of this study, we believe its utility may not be suitable for a direct comparison with the established workflow of our operating microscope. In addition, there is no evidence that single-level laminectomy SDR via small incision is superior to a traditional open laminoplasty technique as described by us. However, we are keen to maximize the advantage of the 3D surgical exoscope's excellent magnification by modifying our surgical approach via smaller incision and look forward to reducing operating times as part of our future work.
SPEAKER: To our knowledge, this is the first reported case of the utility of a 3D exoscope system for SDR in a pediatric patient. Our references are presented within the parentheses.
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