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Medicina
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Clinical Applications of Modern Technologies in Neurosurgery and Spine Surgery
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Clinical Applications of Modern Technologies in Neurosurgery and Spine Surgery

A special issue of Medicina (ISSN 1648-9144). This special issue belongs to the section "Neurology".

Deadline for manuscript submissions: closed (31 August 2024) | Viewed by 8384

Special Issue Editors

Dr. Mirza Pojskić

E-Mail Website
Guest Editor
Department of Neurosurgery, University Hospital Marburg, Philipps University Marburg, Marburg, Germany
Interests: modern technologies in neurosurgery and spine surgery; augmented reality; robotics; skull base surgery; neuro-oncology
Special Issues, Collections and Topics in MDPI journals
Prof. Dr. Christopher Nimsky

E-Mail Website
Guest Editor
Department of Neurosurgery, University Hospital Marburg, Philipps University Marburg, Marburg, Germany
Interests: modern technologies in neurosurgery and spine surgery; augmented reality; intraoperative imaging; neuro-oncology; skull base surgery; pituitary surgery neurovascular surgery; robotics
Special Issues, Collections and Topics in MDPI journals
Dr. Miriam Bopp

E-Mail Website
Guest Editor
Department of Neurosurgery, University Hospital Marburg, Philipps University Marburg, Marburg, Germany
Interests: modern technologies in neurosurgery and spine surgery; augmented reality; intraoperative imaging; MRI

Special Issue Information

Dear Colleagues, 

The development of neurosurgery and spine surgery is closely related to the introduction and use of modern technologies, which rapidly change the treatment of cranial and spinal diseases. Improvements in preoperative imaging and reconstructions of the related pathology, which are then used for proper surgical planning, and applications of the latest technologies for the improvement of orientation in the surgical field and facilitation of the operative approach, use, and development of technology are irreplaceable tools for optimal operative treatment and outcome of patients with complex lesions of the brain and spine. Use of neuronavigation has become a standard of care for neurosurgery and spine surgery, and its advances lead to the improvement of safety of surgery and outcome of patients. Intraoperative imaging with intraoperative ultrasound, computer tomography, and magnetic resonance imaging provides an up-to-date overview of the surgical field and provides a possibility to adjust surgical strategy accordingly. Recent advances in augmented and virtual reality have permanently changed the way the structures of interest are presented through an operative microscope, with further development in our understanding of the complex anatomy of the brain and spine. The development of endoscopy for intraventricular pathology, skull base surgery, and—more recently—spine surgery provides minimally invasive access to various regions of the central and peripheral nervous system and is an effective tool which can be used alone or in combination with the microscopic technique. The establishment and continuous development of intraoperative neuromonitoring and electrophysiology leads to significant improvement in patient outcomes, especially in surgery of the pontocerebellar angle and surgery for intramedullary tumors of the spinal cord. Lastly, the development of robotics for spine surgery as well as functional neurosurgery, for improved accuracy of implant placement, is still at its early stage of development but becoming an irreplaceable tool for selected cases where the accurate position of a screw or an electrode is vital for optimal patient outcome.

In this Special Issue of Medicina, we aim to publish articles on clinical applications of modern technologies in neurosurgery and spine surgery in as broad a context as possible to provide the readers with a comprehensive overview of the latest developments.

Clinical, neuroradiological, as well as experimental, basic science research, in respect of clinical applications of modern technologies in neurosurgery and spine surgery, is welcome. Papers on preoperative imaging, new and innovative surgical approaches and techniques, as well as application of various novel technologies, devices, as well as surgical concepts are of interest.

Case reports, retrospective and prospective case series and studies, operative videos, technical notes, literature reviews, opinions, and clinical and basic science research are all welcome.

Dr. Mirza Pojskić
Prof. Dr. Christopher Nimsky
Dr. Miriam Bopp
Guest Editors

Manuscript Submission Information

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Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Medicina is an international peer-reviewed open access monthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2200 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • modern technologies
  • neuronavigation
  • augmented reality
  • virtual reality
  • robotics
  • endoscopy
  • tumor treating fields
  • tumor biology
  • intraoperative ultrasound
  • intraoperative computed tomography
  • intraoperative magnetic resonance imaging
  • neuroradiology
  • neurosurgery
  • spine surgery

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Published Papers (5 papers)

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Research

12 pages, 7879 KiB  
Article
High-Definition 4K-3D Exoscope in Spine Surgery: A Single-Center Experience and Review of the Literature
by Niccolò Innocenti, Nicoletta Corradino, Francesco Restelli, Vittoria Maria Luisa Cojazzi, Elio Mazzapicchi, Marco Schiariti, Vincenzo Levi and Francesco Costa
Medicina 2024, 60(9), 1476; https://doi.org/10.3390/medicina60091476 - 10 Sep 2024
Viewed by 245
Abstract
Background and Objectives: Binocular optical microscopy (OM) paved the way for a new era in brain and spine neurosurgery fields with the introduction of microsurgery. Despite its enormous contribution to modern neurosurgery, OM presents some intrinsic limitations that surgeons need to face [...] Read more.
Background and Objectives: Binocular optical microscopy (OM) paved the way for a new era in brain and spine neurosurgery fields with the introduction of microsurgery. Despite its enormous contribution to modern neurosurgery, OM presents some intrinsic limitations that surgeons need to face during procedures such as prolonged non-ergonomic positions and decreased vision quality to the assistant eyepiece. To overcome these limitations, in recent years, new operative tools have been introduced, such as exoscopes. Here, we present our experience with exoscopes in spine surgery. Materials and Methods: In the period between January 2022 and December 2023, we gradually implemented the use of a high-definition 4K-3D exoscope (ORBEYETM, Olympus, Japan) in patients undergoing spinal surgery. Results: A total of 243 patients underwent spine surgery with exoscope magnification (47 intradural tumors, 99 lumbar degenerative cases, 79 cervical degenerative cases, 5 dorsal calcified disk herniations, 4 dural arteriovenous fistulas (dAVFs), and 9 others). We compared this cohort with a similar cohort of patients operated in the same period using OM based on different endpoints: operating time, complication rate, and infection rate. We did not find any statistically significant difference in any of the endpoints between these two groups. Conclusions: In our experience, the exoscope provides a better resolution of spinal anatomy and higher quality real-time images of the surgery for the entire OR team and improves the ergonomic posture of both surgeons, without lengthening the operating time and without increasing the rate of adverse events. Prospective studies with a larger cohort of patients are needed to further validate these findings. Full article
(This article belongs to the Special Issue Clinical Applications of Modern Technologies in Neurosurgery and Spine Surgery)
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Figure 1

Figure 1
<p>Operative room setup during the resection of a lumbar intradural tumor.</p> Full article ">Figure 2
<p>Representation of Operative room setup during spine procedure with intraoperative imaging acquisition system and navigation system.</p> Full article ">Figure 3
<p>(<b>a</b>) Senior surgeon explaining the junior surgeon how to proceed during bone decompression during the resection of dorsal dumbbell schwannoma; (<b>b</b>) senior surgeon following the surgery with the same 4K-3D vision of the operating surgeon without being directly on the operating field.</p> Full article ">
13 pages, 30186 KiB  
Communication
Posterior-Only T11 Vertebral Column Resection for Pediatric Congenital Kyphosis Surgical Correction
by Pawel Grabala, Negin Fani, Jerzy Gregorczyk and Michal Grabala
Medicina 2024, 60(6), 897; https://doi.org/10.3390/medicina60060897 - 29 May 2024
Cited by 1 | Viewed by 950
Abstract
Background: Congenital kyphosis is a spinal deformity that arises from the inadequate anterior development or segmentation of the vertebrae in the sagittal plane during the initial embryonic stage. Consequently, this condition triggers atypical spinal growth, leading to the manifestation of deformity. Concurrently, [...] Read more.
Background: Congenital kyphosis is a spinal deformity that arises from the inadequate anterior development or segmentation of the vertebrae in the sagittal plane during the initial embryonic stage. Consequently, this condition triggers atypical spinal growth, leading to the manifestation of deformity. Concurrently, other congenital abnormalities like renal or cardiac defects within the gastrointestinal tract may co-occur with spinal deformities due to their shared formation timeline. In light of the specific characteristics of the deformity, the age range of the patient, deformity sizes, and neurological conditions, surgical intervention emerges as the optimal course of action for such cases. The selection of the appropriate surgical approach is contingent upon the specific characteristics of the anomaly. Case Presentation: This investigation illustrates the utilization of a surgical posterior-only strategy for correcting pediatric congenital kyphoscoliosis through the implementation of a vertebral column resection method along with spine reconstruction employing a mesh cage. The individual in question, a 16-year-old female, exhibited symptoms such as a progressive rib hump, shoulder asymmetry, and back discomfort. Non-invasive interventions like bracing proved ineffective, leading to the progression of the spinal curvature. After the surgical procedure, diagnostic imaging displayed a marked enhancement across all three spatial dimensions. After a postoperative physical assessment, it was noted that the patient experienced significant enhancements in shoulder alignment and rib hump prominence, with no discernible neurological or other adverse effects. Conclusions: Surgical intervention is considered the optimal approach for addressing such congenital anomalies. Typically, timely surgical intervention leads to favorable results and has the potential to halt the advancement of deformity and curvature enlargement. Full article
(This article belongs to the Special Issue Clinical Applications of Modern Technologies in Neurosurgery and Spine Surgery)
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Figure 1

Figure 1
<p>Clinical pictures of the 16-year-old female before surgical treatment. The girl presented with severe congenital kyphosis with a thoraco-lumbar progressed hump.</p> Full article ">Figure 2
<p>Standard standing AP and lateral X-rays and side-bending films of the 16-year-old female before surgical treatment. These X-rays showed severe and stiff congenital kyphosis.</p> Full article ">Figure 3
<p>MRI scans showed spinal cord compression in the 16-year-old female before surgical treatment.</p> Full article ">Figure 4
<p>Pedicle screw placement using a free-hand technique under neuromonitoring control from T5 to L3; transverse process hook placed bilaterally at T4 to prevent pullout, and PJK, peri-apical Ponte’s osteotomies (at T9–L1).</p> Full article ">Figure 5
<p>Temporary rod placed, P-VCR at T11 performing power burr, preparing for placement of a titanium mesh cage for anterior column reconstruction.</p> Full article ">Figure 6
<p>The deformity correction via compression and in situ techniques, and temporary rods being bent and replaced with contoured rods to achieve adequate sagittal and coronal balance.</p> Full article ">Figure 7
<p>Final correction performed with three 6.0 Co-chr rods.</p> Full article ">Figure 8
<p>Standard standing AP (<b>a</b>) and lateral (<b>b</b>) X-rays of the 16-year-old female after undergoing surgical treatment. These X-rays were performed just after surgery.</p> Full article ">Figure 9
<p>Clinical pictures of the 16-year-old female after surgical treatment.</p> Full article ">Figure 10
<p>Standard standing AP (<b>a</b>) and lateral (<b>b</b>) X-rays of the 16-year-old female after undergoing surgical treatment at 2 years of follow-up.</p> Full article ">Figure 11
<p>3D-computer tomography reconstruction of the whole spine of the 16-year-old female after undergoing surgical treatment at 2 years of follow-up. The pictures show spondylodesis of the posterior and anterior columns.</p> Full article ">
18 pages, 10140 KiB  
Article
Surgical Treatment of Calcified Thoracic Herniated Disc Disease via the Transthoracic Approach with the Use of Intraoperative Computed Tomography (iCT) and Microscope-Based Augmented Reality (AR)
by Mirza Pojskić, Miriam H. A. Bopp, Christopher Nimsky and Benjamin Saß
Medicina 2024, 60(6), 887; https://doi.org/10.3390/medicina60060887 - 28 May 2024
Viewed by 915
Abstract
Background and Objectives: The aim of this study is to present our experience in the surgical treatment of calcified thoracic herniated disc disease via a transthoracic approach in the lateral position with the use of intraoperative computed tomography (iCT) and augmented reality [...] Read more.
Background and Objectives: The aim of this study is to present our experience in the surgical treatment of calcified thoracic herniated disc disease via a transthoracic approach in the lateral position with the use of intraoperative computed tomography (iCT) and augmented reality (AR). Materials and Methods: All patients who underwent surgery for calcified thoracic herniated disc via a transthoracic transpleural approach at our Department using iCT and microscope-based AR were included in the study. Results: Six consecutive patients (five female, median age 53.2 ± 6.4 years) with calcified herniated thoracic discs (two patients Th 10–11 level, two patients Th 7–8, one patient Th 9–10, one patient Th 11–12) were included in this case series. Indication for surgery included evidence of a calcified thoracic disc on magnet resonance imaging (MRI) and CT with spinal canal stenosis of >50% of diameter, intractable pain, and neurological deficits, as well as MRI-signs of myelopathy. Five patients had paraparesis and ataxia, and one patient had no deficit. All surgeries were performed in the lateral position via a transthoracic transpleural approach (Five from left side). CT for automatic registration was performed following the placement of the reference array, with a high registration accuracy. Microscope-based AR was used, with segmented structures of interest such as vertebral bodies, disc space, herniated disc, and dural sac. Mean operative time was 277.5 ± 156 min. The use of AR improved orientation in the operative field for identification, and tailored the resection of the herniated disc and the identification of the course of dural sac. A control-iCT scan confirmed the complete resection in five patients and incomplete resection of the herniated disc in one patient. In one patient, complications occurred, such as postoperative hematoma, and wound healing deficit occurred. Mean follow-up was 22.9 ± 16.5 months. Five patients improved following surgery, and one patient who had no deficits remained unchanged. Conclusions: Optimal surgical therapy in patients with calcified thoracic disc disease with compression of dural sac and myelopathy was resectioned via a transthoracic transpleural approach. The use of iCT-based registration and microscope-based AR significantly improved orientation in the operative field and facilitated safe resection of these lesions. Full article
(This article belongs to the Special Issue Clinical Applications of Modern Technologies in Neurosurgery and Spine Surgery)
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Figure 1
<p>Lateral decubitus position of the patient for a left lateral transthoracic transpleural approach (patient Number 6).</p> Full article ">Figure 2
<p>Use of standard C-arm X-ray for level definition prior to skin incision (same as <a href="#medicina-60-00887-f001" class="html-fig">Figure 1</a>).</p> Full article ">Figure 3
<p>Rigid fusion of levels of interest, with the segmented vertebras in yellow and the herniated disc in blue in the axial, coronal, and sagittal views (patient number 3).</p> Full article ">Figure 4
<p>3D reconstruction of the intraoperative registration scan, which depicts the position of the retractor in relation to the segmented vertebras Th7 and Th8 in yellow and the herniated disc in blue.</p> Full article ">Figure 5
<p>Patient number 2 with a Th11–12 thoracic disc operated via right lateral transthoracic transpleural approach following the resection of the disc. (<b>A</b>) Overview visualization depicting the position of the microscope view in relation to the segmented structures in 3D (vertebras in yellow, herniated disc in blue, screws in blue). (<b>B</b>) Probe’s-eye view with segmented structures in the iCT. (<b>C</b>) Segmented objects visualized separately in target view. (<b>D</b>) A 3D rendering of the iCT images, illustrating how the video frame is placed in relation to the image data.</p> Full article ">Figure 6
<p>Patient No. 3. Preoperative. (<b>A</b>) T2-weighted sagittal and (<b>B</b>) T2-weighted axial MRI with preoperative (<b>C</b>) sagittal and (<b>D</b>) axial view of the calcified Th7/8 disc with myelopathy.</p> Full article ">Figure 7
<p>Patient No. 3, intraoperative view following the automatic registration of the patient with an iCT and the calibration of the microscope. Microscope focus is on the herniated disc (blue), with segmented vertebras Th 7/8 in yellow and the retractor in green, with a depiction in the intraoperative registration scan in the (<b>A</b>) axial and (<b>B</b>) coronal view, as well as in the preoperative scan in the (<b>C</b>) axial and (<b>D</b>) coronal view.</p> Full article ">Figure 8
<p>Patient No. 3, depiction of segmented vertebras in yellow and herniated disc in blue in preoperative (<b>A</b>,<b>B</b>) sagittal and (<b>A1</b>,<b>B1</b>). Axial CT with same segmented structure in intraoperative, control iCT scan following complete resection of the disc in (<b>C</b>,<b>D</b>) sagittal and (<b>C1</b>,<b>D1</b>) axial view.</p> Full article ">Figure 9
<p>Patient No. 4 (<b>A</b>) Preoperative and (<b>B</b>) postoperative sagittal T2-weighted MRI of the thoracic spine with (<b>C</b>) preoperative and (<b>D</b>) postoperative sagittal CT of the thoracic spine following complete resection of the Th9/10 disc.</p> Full article ">Figure 10
<p>Patient No. 5, preoperative CT shows the herniated disc at the Th10–11 level with ossification of the posterior longitudinal ligament in the (<b>A</b>) sagittal and (<b>B</b>) axial view.</p> Full article ">Figure 11
<p>Patient No 5. with a Th10–11 thoracic disc operated via a left lateral transthoracic transpleural approach following the resection of the disc. (<b>A</b>) Overview visualization depicting the position of the microscope view in relation to the segmented structures in 3D (vertebras and disc in yellow, dural sac in green). (<b>B</b>) Probe’s-eye view, with segmented structures in the iCT. (<b>C</b>) Segmented objects visualized separately in target view. (<b>D</b>) A 3D rendering of the iCT images, illustrating how the video frame is placed in relation to the image data.</p> Full article ">Figure 12
<p>Patient No 5. sagittal view of (<b>A</b>) registration scan iCT prior to resection and (<b>B</b>) control iCT scan, which depicts the complete resection of the disc. Vertebras are segmented in orange, the disc in yellow, and the dural sac in green.</p> Full article ">Figure 13
<p>Patient No. 5. Preoperative T2-weighted (<b>A</b>) sagittal and (<b>B</b>) axial MRI with postoperative T2-weighted (<b>C</b>) sagittal and (<b>D</b>) T1-weighted post-contrast axial MRI of the thoracic spine, which shows the complete resection of the herniated disc.</p> Full article ">Figure 14
<p>Patient No 6. with calcified T11–12 disc operated via a left lateral transthoracic transpleural approach at the beginning of microsurgical resection. (<b>A</b>) Overview visualization depicting the position of the microscope view in relation to the segmented structures in 3D (vertebras in yellow, herniated disc in red, dural sac in purple). (<b>B</b>) Probe’s-eye view with segmented structures in the MRI. (<b>C</b>) Segmented objects visualized separately in the target view. (<b>D</b>) A 3D rendering of the iCT images illustrating how the video frame is placed in relation to the image data.</p> Full article ">Figure 15
<p>Patient No. 6 with calcified T11–12 disc operated via a left lateral transthoracic transpleural following the complete resection of the disc and anterior decompression with exposure of the dural sac. (<b>A</b>) Overview visualization depicting the position of the microscope view in relation to the segmented structures in 3D (vertebras in yellow, herniated disc in red, dural sac in purple). (<b>B</b>) Probe’s-eye view with segmented structures in the MRI. (<b>C</b>) Segmented objects visualized separately in target view. (<b>D</b>) A 3D rendering of the iCT images illustrating how the video frame is placed in relation to the image data.</p> Full article ">Figure 16
<p>Patient No. 6. A. Preoperative T2-weighted sagittal MRI of the lumbar spine shows the herniated disc at Th11–12 level, with (<b>B</b>) the postoperative sagittal T2-weighted MRI of the thoracic spine, which shows the complete resection of the disc.</p> Full article ">
15 pages, 9315 KiB  
Article
Breaking Barriers in Cranioplasty: 3D Printing in Low and Middle-Income Settings—Insights from Zenica, Bosnia and Herzegovina
by Hakija Bečulić, Denis Spahić, Emir Begagić, Ragib Pugonja, Rasim Skomorac, Aldin Jusić, Edin Selimović, Anes Mašović and Mirza Pojskić
Medicina 2023, 59(10), 1732; https://doi.org/10.3390/medicina59101732 - 27 Sep 2023
Cited by 4 | Viewed by 3123
Abstract
Background and Objectives: Cranial defects pose significant challenges in low and middle-income countries (LIMCs), necessitating innovative and cost-effective craniofacial reconstruction strategies. The purpose of this study was to present the Bosnia and Herzegovina model, showcasing the potential of a multidisciplinary team and 3D-based [...] Read more.
Background and Objectives: Cranial defects pose significant challenges in low and middle-income countries (LIMCs), necessitating innovative and cost-effective craniofacial reconstruction strategies. The purpose of this study was to present the Bosnia and Herzegovina model, showcasing the potential of a multidisciplinary team and 3D-based technologies, particularly PMMA implants, to address cranial defects in a resource-limited setting. Materials and Methods: An observational, non-experimental prospective investigation involved three cases of cranioplasty at the Department of Neurosurgery, Cantonal Hospital Zenica, Bosnia and Herzegovina, between 2019 and 2023. The technical process included 3D imaging and modeling with MIMICS software (version 10.01), 3D printing of the prototype, mold construction and intraoperative modification for precise implant fitting. Results: The Bosnia and Herzegovina model demonstrated successful outcomes in cranioplasty, with PMMA implants proving cost-effective and efficient in addressing cranial defects. Intraoperative modification contributed to reduced costs and potential complications, while the multidisciplinary approach and 3D-based technologies facilitated accurate reconstruction. Conclusions: The Bosnia and Herzegovina model showcases a cost-effective and efficient approach for craniofacial reconstruction in LIMICs. Collaborative efforts, 3D-based technologies, and PMMA implants contribute to successful outcomes. Further research is needed to validate sustained benefits and enhance craniofacial reconstruction strategies in resource-constrained settings. Full article
(This article belongs to the Special Issue Clinical Applications of Modern Technologies in Neurosurgery and Spine Surgery)
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Figure 1
<p>MIMICS software interface.</p> Full article ">Figure 2
<p>Mirror technique in the preparation of the missing part of the calvaria: (<b>a</b>) cutting and checking the match with the defect, and (<b>b</b>) isolated reconstructed part corresponding to the defect.</p> Full article ">Figure 3
<p>A PLA prototype matching the bone defect (<b>a</b>) and a negative prototype—a mold used for intraoperative adaptation of the implant (<b>b</b>).</p> Full article ">Figure 4
<p>First case with (<b>a</b>) frontal and (<b>b</b>) lateral aspect preoperative images.</p> Full article ">Figure 5
<p>Second case with (<b>a</b>) frontal and (<b>b</b>) lateral aspect preoperative images.</p> Full article ">Figure 6
<p>Second case CT scan: (<b>a</b>) transverse slice, and (<b>b</b>) CT-based 3D reconstruction.</p> Full article ">Figure 7
<p>Presence of intracerebral bleeding in first case (<b>a</b>) after DC ischemic zone in the right frontal, and parietal lobes due to MCA occlusion in third case (<b>b</b>).</p> Full article ">Figure 8
<p>Intraoperative processing of the PMMA implant: (<b>a</b>) PMMA mass adapting using mold; (<b>b</b>) grinding and finishing of implant.</p> Full article ">Figure 9
<p>Implantation of PMMA implant (<b>a</b>), and closure (<b>b</b>).</p> Full article ">Figure 10
<p>Presentation of Case 1 (<b>a</b>) after the surgical procedure, after the removal of the stapler pins, after 10 days, and Case 2 (<b>b</b>) postoperatively 6 days before the removal of the stapler pins.</p> Full article ">Figure 11
<p>Preoperative and follow-up ANA score.</p> Full article ">Figure 12
<p>Overview chart with proposed steps for implementing the process and procedure of CP in LIMCs.</p> Full article ">
15 pages, 2570 KiB  
Article
The Brainstem Cavernoma Case Series: A Formula for Surgery and Surgical Technique
by Marcos Tatagiba, Guilherme Lepski, Marcel Kullmann, Boris Krischek, Soeren Danz, Antje Bornemann, Jan Klein, Antje Fahrig, Tomaz Velnar and Guenther C. Feigl
Medicina 2023, 59(9), 1601; https://doi.org/10.3390/medicina59091601 - 5 Sep 2023
Cited by 1 | Viewed by 2037
Abstract
Background and Objectives: Cavernous malformations (CM) are vascular malformations with low blood flow. The removal of brainstem CMs (BS) is associated with high surgical morbidity, and there is no general consensus on when to treat deep-seated BS CMs. The aim of this [...] Read more.
Background and Objectives: Cavernous malformations (CM) are vascular malformations with low blood flow. The removal of brainstem CMs (BS) is associated with high surgical morbidity, and there is no general consensus on when to treat deep-seated BS CMs. The aim of this study is to compare the surgical outcomes of a series of deep-seated BS CMs with the surgical outcomes of a series of superficially located BS CMs operated on at the Department of Neurosurgery, College of Tuebingen, Germany. Materials and Methods: A retrospective evaluation was performed using patient charts, surgical video recordings, and outpatient examinations. Factors were identified in which surgical intervention was performed in cases of BS CMs. Preoperative radiological examinations included MRI and diffusion tensor imaging (DTI). For deep-seated BS CMs, a voxel-based 3D neuronavigation system and electrophysiological mapping of the brainstem surface were used. Results: A total of 34 consecutive patients with primary superficial (n = 20/58.8%) and deep-seated (n = 14/41.2%) brainstem cavernomas (BS CM) were enrolled in this comparative study. Complete removal was achieved in 31 patients (91.2%). Deep-seated BS CMs: The mean diameter was 14.7 mm (range: 8.3 to 27.7 mm). All but one of these lesions were completely removed. The median follow-up time was 5.8 years. Two patients (5.9%) developed new neurologic deficits after surgery. Superficial BS CMs: The median diameter was 14.9 mm (range: 7.2 to 27.3 mm). All but two of the superficial BS CMs could be completely removed. New permanent neurologic deficits were observed in two patients (5.9%) after surgery. The median follow-up time in this group was 3.6 years. Conclusions: The treatment of BS CMs remains complex. However, the results of this study demonstrate that with less invasive posterior fossa approaches, brainstem mapping, and neuronavigation combined with the use of a blunt “spinal cord” dissection technique, deep-seated BS CMs can be completely removed in selected cases, with good functional outcomes comparable to those of superficial BS CM. Full article
(This article belongs to the Special Issue Clinical Applications of Modern Technologies in Neurosurgery and Spine Surgery)
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Figure 1

Figure 1
<p>Flowchart describing the decision-making process for surgical and conservative treatment of patients with BS CM, including the “Tuebingen brainstem cavernoma equation”, where (<span class="html-italic">D</span>) is the distance from the lesion to the surface of the brainstem, which must be equal to or less than half the largest diameter (<span class="html-italic">ld</span>) of the lesion when measured on an axial T1 image. For progressivity check (the right part of the diagram), an MRI is essential. It is not possible to reach a decision without MRI assessment. * is the designation of imaging.</p> Full article ">Figure 2
<p>Screenshot of intraoperative neuronavigation (CBYON™—Med-Surgical Services Inc., Sunnyvale, CA, USA) showing the “virtual endoscopic” view (<b>top left</b> image) through the tip of the pointer (<b>top right</b> image) with 3D volume image rendering and modified opacity of the tissue layers, revealing the deep-seated cavernoma (blue) in the pons and guiding the neurosurgeon to a safe entry point.</p> Full article ">Figure 3
<p>Location of the craniotomy (<b>A</b>), transection of the dura (<b>B</b>), and insertion of the spatula (<b>C</b>).</p> Full article ">Figure 4
<p>The following figures show the sequential steps of microsurgical resection of the cavernoma through a retrosigmoidal approach to the cerebello-pontine angle. The opening of the pial surface of the brainstem with microscissors (<b>A</b>). The bimanual opening and expansion of the brainstem with two microdissectors by blunt dissection (<b>B</b>). The viscoelasticity of the brainstem facilitates blunt dissection and allows for the gentle and safe access to the cavernoma. Micro-tumour forceps holding the cavernous malformation and micro-bayonet dissection forceps and carefully separating the cavernous malformation from the brainstem tissue (<b>C</b>).</p> Full article ">Figure 5
<p>Preoperative axial (<b>A</b>) and sagittal (<b>B</b>) T2 MR images of a 35-year-old woman showing a deep-seated cavernous malformation in the midbrain on the right side. The patient had been suffering from headaches and gait disturbances for several weeks.</p> Full article ">Figure 6
<p>Postoperative axial (<b>A</b>) T1 and coronal T2 images (<b>B</b>) MR show that complete removal of the deep-seated cavernous malformation of the brainstem was achieved. The coronal image on the right shows the entry site into the brainstem (white arrow) through which the cavernoma was accessed. The patient was neurologically stable after surgery. She had no new neurologic deficits after surgery, either in the immediate postoperative period or during the 3-month follow-up.</p> Full article ">Figure 7
<p>Preoperative axial (<b>A</b>), coronal (<b>B</b>), and sagittal (<b>C</b>) T2 images MR of a 35-year-old woman showing a superficial cavernoma in the pons on the right side. The patient suffered from headaches and gait disturbances for several weeks.</p> Full article ">Figure 8
<p>Postoperative axial (<b>A</b>), coronal (<b>B</b>), and sagittal (<b>C</b>) T1 images MR with contrast enhancement showing that complete removal of the superficial cavernous malformation of the pons was achieved. In the coronal image in the centre, the microsurgical entry site into the brainstem can be seen (white arrow). After surgery, no new neurologic deficits occurred in the immediate postoperative period or during the 3-month follow-up.</p> Full article ">Figure 9
<p>Illustration of the “Tuebingen brainstem cavernoma equation” used to determine whether a deep-seated lesion is close enough to the surface of the brainstem to be safely removed surgically. <span class="html-italic">D</span> is the shortest distance of the lesion (red circle) to the surface of the brainstem and should be equal to or less than half of the largest diameter (<span class="html-italic">ld</span>) of the lesion measured on an axial T1 scan.</p> Full article ">
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