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Suero Molina E, Bruneau M, Reuter G, Shahein M, Cavallo LM, Daniel RT, Kasper EM, Froelich S, Jouanneau E, Manet R, Messerer M, Mazzatenta D, Meling TR, Roche PH, Schroeder HWS, Tatagiba M, Visocchi M, Prevedello DM, Stummer W, Cornelius JF. Fluorescence guidance in skull base surgery: Applications and limitations - A systematic review. BRAIN & SPINE 2024; 4:103328. [PMID: 39309550 PMCID: PMC11416557 DOI: 10.1016/j.bas.2024.103328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 08/18/2024] [Accepted: 08/27/2024] [Indexed: 09/25/2024]
Abstract
Introduction Intraoperative fluorescence guidance is a well-established surgical adjunct in high-grade glioma surgery. In contrast, the clinical use of such dyes and technology has been scarcely reported in skull base surgery. Research question We aimed to systematically review the clinical applications of different fluorophores in both open and endonasal skull base surgery. Material and methods We performed a systematic review and discussed the current literature on fluorescence guidance in skull base surgery. Results After a comprehensive literature search, 77 articles on skull base fluorescence guidance were evaluated. A qualitative analysis of the articles is presented, discussing clinical indications and current controversies. The use of intrathecal fluorescein was the most frequently reported in the literature. Beyond that, 5-ALA and ICG were two other fluorescent dyes most extensively discussed, with some experimental fluorophore applications in skull base surgery. Discussion and conclusion Intraoperative fluorescence imaging can serve as an adjunct technology in skull base surgery. The scope of initial indications of these fluorophores has expanded beyond malignant glioma resection alone. We discuss current use and controversies and present an extensive overview of additional indications for fluorescence imaging in skull base pathologies. Further quantitative studies will be needed in the future, focusing on tissue selectivity and time-dependency of the different fluorophores currently commercially available, as well as the development of new compounds to expand applications and facilitate skull base surgeries.
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Affiliation(s)
- Eric Suero Molina
- Department of Neurosurgery, University Hospital of Münster, Münster, Germany
- Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Michael Bruneau
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Gilles Reuter
- Department of Neurosurgery, University Hospital of Liège, Liège, Belgium
| | | | - Luigi M. Cavallo
- Department of Neurosciences and Reproductive and Dental Sciences, Division of Neurosurgery, Federico II University of Naples, Policlinico Federico II University Hospital, Italy
| | - Roy T. Daniel
- Department of Neurosurgery, Department of Neuroscience, Centre Hospitalier Universitaire Vaudois, University Hospital Lausanne, Switzerland
| | - Ekkehard M. Kasper
- Department of Neurosurgery, Boston University Medical School, MA and Steward Medical Group, Brighton, MA/USA McMaster University Faculty of Health Sciences, Hamilton, ON, Canada
| | - Sebastien Froelich
- Department of Neurosurgery, Lariboisière Hospital, Université Paris Diderot, Paris, France
| | - Emanuel Jouanneau
- Department of Neurosurgery, Hôpital Neurologique Pierre Wertheimer, Lyon, France
| | - Romain Manet
- Department of Neurosurgery, Hôpital Neurologique Pierre Wertheimer, Lyon, France
| | - Mahmoud Messerer
- Department of Neurosciences and Reproductive and Dental Sciences, Division of Neurosurgery, Federico II University of Naples, Policlinico Federico II University Hospital, Italy
| | - Diego Mazzatenta
- Department of Neurosurgery, Neurological Sciences Institut IRCCS, Bologna, Italy
| | - Torstein R. Meling
- Department of Neurosurgery, The National Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Pierre-Hugues Roche
- Department of Neurosurgery, Aix-Marseille Université, Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, Marseille, France
| | | | - Marcos Tatagiba
- Department of Neurosurgery, University Hospital Tübingen, Tübingen, Germany
| | - Massimiliano Visocchi
- Department of Neurosurgery, Institute of Neurosurgery Catholic University of Rome, Italy
| | - Daniel M. Prevedello
- Deparmtent of Neurosurgery, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Walter Stummer
- Department of Neurosurgery, University Hospital of Münster, Münster, Germany
| | - Jan F. Cornelius
- Department of Neurosurgery, University Hospital of Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - EANS Skull Base Section
- Department of Neurosurgery, University Hospital of Münster, Münster, Germany
- Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium
- Department of Neurosurgery, University Hospital of Liège, Liège, Belgium
- Department of Neurosurgery, Mansoura University, Egypt
- Department of Neurosciences and Reproductive and Dental Sciences, Division of Neurosurgery, Federico II University of Naples, Policlinico Federico II University Hospital, Italy
- Department of Neurosurgery, Department of Neuroscience, Centre Hospitalier Universitaire Vaudois, University Hospital Lausanne, Switzerland
- Department of Neurosurgery, Boston University Medical School, MA and Steward Medical Group, Brighton, MA/USA McMaster University Faculty of Health Sciences, Hamilton, ON, Canada
- Department of Neurosurgery, Lariboisière Hospital, Université Paris Diderot, Paris, France
- Department of Neurosurgery, Hôpital Neurologique Pierre Wertheimer, Lyon, France
- Department of Neurosurgery, Neurological Sciences Institut IRCCS, Bologna, Italy
- Department of Neurosurgery, The National Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Neurosurgery, Aix-Marseille Université, Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, Marseille, France
- Department of Neurosurgery, University Medicine Greifswald, Germany
- Department of Neurosurgery, University Hospital Tübingen, Tübingen, Germany
- Department of Neurosurgery, Institute of Neurosurgery Catholic University of Rome, Italy
- Deparmtent of Neurosurgery, The Ohio State University College of Medicine, Columbus, OH, USA
- Department of Neurosurgery, University Hospital of Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
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2
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Gosselin LE, Morin N, Gariépy C, Chamberland M, Beaulieu O, Nadeau S, Champagne PO. Development and Validation of a Novel Human-Fixed Cadaveric Model Reproducing Cerebrospinal Fluid Circulation for Simulation of Endoscopic Endonasal Skull Base Surgery. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01248. [PMID: 38995026 DOI: 10.1227/ons.0000000000001272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Accepted: 05/20/2024] [Indexed: 07/13/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Endoscopic endonasal surgery is a well-established surgical approach to the skull base. Surgeons need a reusable long-lasting tool to acquire the skills needed for skull base reconstruction. The aim of this study was to elaborate and validate a human formalin-fixed cadaveric model that reproduces a realistic cerebrospinal fluid (CSF) circulation and that adequately renders a CSF leak. METHODS An external ventricular drain that connects with a peristaltic pump is placed in the subarachnoid space, which allows a water circulation that reproduces CSF circulation. Intracranial pressure is measured in real time. Endoscopic endonasal skull base approaches are performed, to create different skull base openings and CSF leaks. Participants were tasked with reconstruction of the defects using a standardized multilayered approach, with the goal of obtaining a watertight closure under normal intracranial pressure ranges. Compiled data included time of reconstruction, years of experience of participants, and success/failure to achieve a watertight reconstruction. A Likert questionnaire was also used. RESULTS The cadaveric model reproduced CSF circulation in 4 types of dural defects: sellar, suprasellar, transcribriform, and transclival. Intracranial pressures were similar to physiological conditions and were reproducible. Each model was tested multiple times, over several months. Success rates concurred with training levels (r = .8282 and P = .0017). A strong inverse correlation was also found between years of experience and time of reconstruction (r = .4977 and P < .0001). Participants agreed that the model was realistic (median Likert score of 4), and they strongly agreed that it allowed for the improvement of their surgical skills (median Likert score of 5). CONCLUSION This novel human-fixed cadaveric model for CSF circulation is efficient and adequately reproduces surgical conditions for skull base approaches. The model is unique, easy to reproduce, and reusable. It can be used as a tool for teaching and for research purposes.
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Affiliation(s)
- Laura-Elisabeth Gosselin
- Department of Otolaryngology - Head and Neck Surgery, Université Laval, Quebec, Québec, Canada
- Université Laval Neurosurgical Innovation Laboratory (ULNIL), Quebec, Québec, Canada
| | - Nicolas Morin
- Université Laval Neurosurgical Innovation Laboratory (ULNIL), Quebec, Québec, Canada
- Department of Neurosurgery, Université Laval, Quebec, Québec, Canada
| | - Charles Gariépy
- Department of Neurosurgery, Université Laval, Quebec, Québec, Canada
| | - Mathieu Chamberland
- Department of Otolaryngology - Head and Neck Surgery, Université Laval, Quebec, Québec, Canada
| | - Olivier Beaulieu
- Department of Otolaryngology - Head and Neck Surgery, Université Laval, Quebec, Québec, Canada
| | - Sylvie Nadeau
- Department of Otolaryngology - Head and Neck Surgery, Centre Hospitalier Universitaire de Québec-Université Laval, Quebec, Québec, Canada
| | - Pierre-Olivier Champagne
- Université Laval Neurosurgical Innovation Laboratory (ULNIL), Quebec, Québec, Canada
- Department of Neurosurgery, Centre Hospitalier Universitaire de Québec-Université Laval, Quebec, Québec, Canada
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Jiang T, Charitos D, Justo J, Alcantara T, Grouls M, De Battista J, Passeri T, Froelich S. Combined Transpetrosal Approach: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2024; 26:470-471. [PMID: 38084942 DOI: 10.1227/ons.0000000000001025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 10/19/2023] [Indexed: 03/16/2024] Open
Abstract
INDICATIONS CORRIDOR AND LIMITS OF EXPOSURE This approach is suitable for petroclival lesions medial to V cranial nerve that extend in both middle and posterior fossa. It provides multiple surgical corridors with minimal brain retraction. ANATOMIC ESSENTIALS NEED FOR PREOPERATIVE PLANNING AND ASSESSMENT Several critical neurovascular structures of the petrous bone are at risk during the approach. Meticulous reading of the preoperative images is fundamental. It is mandatory to perform a thin section computed tomography scan, an MRI, and, in case of petroclival meningiomas, a digital subtraction angiography. ESSENTIAL STEPS OF THE PROCEDURE In the first illustrative case, we present our current "mini-combined petrosectomy" with minimal drilling of the labyrinth. Positioning, skin incision, and craniotomy are illustrated in the video. Once all the important neurovascular structures are identified, we perform the anterior and the posterior petrosectomy, with preservation of the endolymphatic sac. We continue with dura mater opening and tentorium cutting. After tumor removal, we can appreciate an unique view of ipsilateral and contralateral cranial nerves, as well as pituitary stalk and major arteries. PITFALLS/AVOIDANCE OF COMPLICATIONS To avoid injuries to the main neurovascular structures, neuronavigation, neuromonitoring, and Doppler can be useful. VARIANTS AND INDICATIONS FOR THEIR USE The second illustrative case shows an extension of the combined petrosectomy to the anterior fossa, this made possible to perform a transsylvian approach for this giant sphenopetroclival meningioma. The patients consented to the procedure and to the publication of his/her images. Appropriate consent was obtained for the publication of the cadaveric images.
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Affiliation(s)
- Tingting Jiang
- Department of Neurosurgery, Lariboisière Hospital, University of Paris Diderot, Paris , France
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Wu KC, Freedman BR, Kwon PS, Torre M, Kent DO, Bi WL, Mooney DJ. A tough bioadhesive hydrogel supports sutureless sealing of the dural membrane in porcine and ex vivo human tissue. Sci Transl Med 2024; 16:eadj0616. [PMID: 38507468 PMCID: PMC11145396 DOI: 10.1126/scitranslmed.adj0616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 02/28/2024] [Indexed: 03/22/2024]
Abstract
Complete sequestration of central nervous system tissue and cerebrospinal fluid by the dural membrane is fundamental to maintaining homeostasis and proper organ function, making reconstruction of this layer an essential step during neurosurgery. Primary closure of the dura by suture repair is the current standard, despite facing technical, microenvironmental, and anatomic challenges. Here, we apply a mechanically tough hydrogel paired with a bioadhesive for intraoperative sealing of the dural membrane in rodent, porcine, and human central nervous system tissue. Tensile testing demonstrated that this dural tough adhesive (DTA) exhibited greater toughness with higher maximum stress and stretch compared with commercial sealants in aqueous environments. To evaluate the performance of DTA in the range of intracranial pressure typical of healthy and disease states, ex vivo burst pressure testing was conducted until failure after DTA or commercial sealant application on ex vivo porcine dura with a punch biopsy injury. In contrast to commercial sealants, DTA remained adhered to the porcine dura through increasing pressure up to 300 millimeters of mercury and achieved a greater maximum burst pressure. Feasibility of DTA to repair cerebrospinal fluid leak in a simulated surgical context was evaluated in postmortem human dural tissue. DTA supported effective sutureless repair of the porcine thecal sac in vivo. Biocompatibility and adhesion of DTA was maintained for up to 4 weeks in rodents after implantation. The findings suggest the potential of DTA to augment or perhaps even supplant suture repair and warrant further exploration.
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Affiliation(s)
- Kyle C. Wu
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Department of Neurosurgery, Wexner Medical Center and James Cancer Hospital, Ohio State University, Columbus, OH 43210, USA
| | - Benjamin R. Freedman
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA 02139, USA
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, MA 02215, USA
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Phoebe S. Kwon
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, MA 02215, USA
| | - Matthew Torre
- Department of Neuropathology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Daniel O. Kent
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, MA 02215, USA
- Department of General Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Wenya Linda Bi
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - David J. Mooney
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA 02139, USA
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, MA 02215, USA
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Santona G, Madoglio A, Mattavelli D, Rigante M, Ferrari M, Lauretti L, Mattogno P, Parrilla C, De Bonis P, Galli J, Olivi A, Fontanella MM, Fiorentino A, Serpelloni M, Doglietto F. Training models and simulators for endoscopic transsphenoidal surgery: a systematic review. Neurosurg Rev 2023; 46:248. [PMID: 37725193 PMCID: PMC10509294 DOI: 10.1007/s10143-023-02149-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/29/2023] [Accepted: 09/02/2023] [Indexed: 09/21/2023]
Abstract
Endoscopic transsphenoidal surgery is a novel surgical technique requiring specific training. Different models and simulators have been recently suggested for it, but no systematic review is available. To provide a systematic and critical literature review and up-to-date description of the training models or simulators dedicated to endoscopic transsphenoidal surgery. A search was performed on PubMed and Scopus databases for articles published until February 2023; Google was also searched to document commercially available. For each model, the following features were recorded: training performed, tumor/arachnoid reproduction, assessment and validation, and cost. Of the 1199 retrieved articles, 101 were included in the final analysis. The described models can be subdivided into 5 major categories: (1) enhanced cadaveric heads; (2) animal models; (3) training artificial solutions, with increasing complexity (from "box-trainers" to multi-material, ct-based models); (4) training simulators, based on virtual or augmented reality; (5) Pre-operative planning models and simulators. Each available training model has specific advantages and limitations. Costs are high for cadaver-based solutions and vary significantly for the other solutions. Cheaper solutions seem useful only for the first stages of training. Most models do not provide a simulation of the sellar tumor, and a realistic simulation of the suprasellar arachnoid. Most artificial models do not provide a realistic and cost-efficient simulation of the most delicate and relatively common phase of surgery, i.e., tumor removal with arachnoid preservation; current research should optimize this to train future neurosurgical generations efficiently and safely.
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Affiliation(s)
- Giacomo Santona
- Department of Information Engineering, University of Brescia, Brescia, Italy
| | - Alba Madoglio
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
- Department of Neurosurgery, Sant' Anna University Hospital, Ferrara, Italy
| | - Davide Mattavelli
- Otorhinolaryngology-Head and Neck Surgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, ASST Spedali Civili of Brescia, University of Brescia, Brescia, Italy
| | - Mario Rigante
- Otorhinolaryngology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Marco Ferrari
- Section of Otorhinolaryngology-Head and Neck Surgery, Department of Neurosciences, University of Padua - Azienda Ospedaliera di Padova, Padua, Italy
| | - Liverana Lauretti
- Neurosurgery, Department of Neurosciences, Sensory Organs and Thorax, Università Cattolica del Sacro Cuore, Rome, Italy
- Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Pierpaolo Mattogno
- Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Claudio Parrilla
- Otorhinolaryngology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Pasquale De Bonis
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
- Department of Neurosurgery, Sant' Anna University Hospital, Ferrara, Italy
| | - Jacopo Galli
- Otorhinolaryngology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Otorhinolaryngology, Department of Neurosciences, Sensory Organs and Thorax, Università Cattolica del Sacro Cuore, Largo Agostino Gemelli, 8, 00168, Rome, Italy
| | - Alessandro Olivi
- Neurosurgery, Department of Neurosciences, Sensory Organs and Thorax, Università Cattolica del Sacro Cuore, Rome, Italy
- Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Marco Maria Fontanella
- Neurosurgery, Department of Medical and Surgical Specialties, Radiologic Sciences, and Public Health, University of Brescia - ASST Spedali Civili di Brescia, Brescia, Italy
| | - Antonio Fiorentino
- Department of Mechanical and Industrial Engineering, University of Brescia, Brescia, Italy
| | - Mauro Serpelloni
- Department of Information Engineering, University of Brescia, Brescia, Italy
| | - Francesco Doglietto
- Neurosurgery, Department of Neurosciences, Sensory Organs and Thorax, Università Cattolica del Sacro Cuore, Rome, Italy.
- Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
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Bir C, Wong M, Villalta R, Lewis M, Sherman D, Matheis E, Inaba K, Rafaels K. Assessment of a Perfusion and Ventilation Method for Detecting Lung and Liver Injury in a Cadaveric Model. Ann Biomed Eng 2023; 51:2048-2055. [PMID: 37266719 PMCID: PMC10237055 DOI: 10.1007/s10439-023-03230-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 05/02/2023] [Indexed: 06/03/2023]
Abstract
Surgical simulation models have been developed using post-mortem human subjects (PMHS). These models involve the pressurization and ventilation of the PMHS to create a more realistic environment for training and the practice of surgical procedures. The overall objective of this study was to determine the feasibility of a previously developed surgical simulation model to detect soft tissue injuries during a ballistic impact to the torso. One of the main limitations of using PMHS for the assessment of soft tissue injuries in the field of injury biomechanics is the lack of physiological blood flow. To overcome this limitation, the assessment of the surgical simulation model for use in injury biomechanics applications was conducted based on data collected from behind armor blunt trauma (BABT) case studies. Documented injuries in real-world cases included anterior lung contusion, posterior lung contusion, and liver contusion. These real-world injuries were compared to those seen post-impact in the PMHS using pathological and histological techniques. Discussion of limitations and future work is presented.
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Affiliation(s)
- Cynthia Bir
- Department of Biomedical Engineering, Wayne State University, 818 W. Hancock, Detroit, MI, 48201, USA.
| | - Monica Wong
- Department of Surgery, Keck School of Medicine, USC, Los Angeles, CA, USA
| | - Rodrigo Villalta
- Department of Surgery, Keck School of Medicine, USC, Los Angeles, CA, USA
| | - Meghan Lewis
- Department of Surgery, Keck School of Medicine, USC, Los Angeles, CA, USA
| | - Donald Sherman
- Department of Biomedical Engineering, Wayne State University, 818 W. Hancock, Detroit, MI, 48201, USA
| | - Erika Matheis
- Bennett Aerospace Inc., DEVCOM Army Research Laboratory, Aberdeen Proving Ground, MD, USA
| | - Kenji Inaba
- Department of Surgery, Keck School of Medicine, USC, Los Angeles, CA, USA
| | - Karin Rafaels
- DEVCOM Army Research Laboratory, Aberdeen Proving Ground, MD, USA
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John A, Collins RA, Nagy L. Endoscopic neuroanatomy study using embalmed cadavers. J Neurosci Rural Pract 2023; 14:377-381. [PMID: 37181189 PMCID: PMC10174146 DOI: 10.25259/jnrp_4_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 01/22/2023] [Indexed: 03/06/2023] Open
Abstract
Objectives A firm understanding of anatomy is foundational for all medical students and residents. As opportunities for cadaveric study dwindle, we propose a simplified perfusion model for formalin fixed cadavers that allow for endoscopic neuroanatomical study and procedural practice. This model is easily accessible, cost effective, and valuable in medical training. Materials and Methods Cadavers were fixed through accepted methods that included formalin injection into the cranial vault. The perfusion system was set up using a series of catheters, tubing, and pressurized saline bag that forced saline into the various neuroanatomical spaces chosen for study. Results A neuroendoscope was subsequently introduced to explore and identify relevant neuroanatomical structures as well as to perform a 3rd ventriculostomy and filum sectioning. Conclusion Using formalin fixed cadavers for neuroendoscopic studies and procedural practice is a cost effective, multipurpose tool that can provide medical trainees with a strong understanding of anatomy as well as procedural practice.
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Affiliation(s)
- Albin John
- Texas Tech University Health Sciences Center, School of Medicine, Lubbock, United States
| | - Reagan A. Collins
- Texas Tech University Health Sciences Center, School of Medicine, Lubbock, United States
| | - Laszlo Nagy
- Department of Pediatrics, Texas Tech University Health Sciences Center, Lubbock, United States
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8
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van Erk M, Lomme RMLM, Roozen EA, van Oirschot BAJA, van Goor H. A novel ex vivo perfusion-based mandibular pig model for dental product testing and training. BMC Oral Health 2023; 23:122. [PMID: 36823579 PMCID: PMC9948382 DOI: 10.1186/s12903-023-02794-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 02/07/2023] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND A translational ex vivo perfusion-based mandibular pig model was developed as an alternative to animal experiments, for initial assessment of biomaterials in dental and maxillofacial surgery and training. This study aimed to assess the face and content validity of the novel perfusion-based model. METHODS Cadaveric porcine heads were connected to an organ assist perfusion device for blood circulation and tissue oxygenation. Dental professionals and dental trainees performed a surgical procedure on the mandibula resembling a submandibular extraoral incision to create bone defects. The bone defects were filled and covered with a commercial barrier membrane. All participants completed a questionnaire using a 5-point Likert scale to assess the face and content validity of the model. Validation data between the two groups of participants were compared with Mann-Whitney U test. RESULTS Ten dental professionals and seven trainees evaluated the model for face and content validity. Participants reported model realism, with a mean face validity score of 3.9 ± 1.0 and a content validity of 4.1 ± 0.8. No significant differences were found for overall face and content validity between experts and trainees. CONCLUSION We established face and content validity in a novel perfusion-based mandibular surgery model. This model can be used as an alternative for animal studies evaluating new biomaterials and related dental and maxillofacial surgical procedural training.
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Affiliation(s)
- Machteld van Erk
- Department of Surgery (Route 618), Radboud University Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Roger M. L. M. Lomme
- Department of Surgery (Route 618), Radboud University Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Edwin A. Roozen
- Department of Surgery (Route 618), Radboud University Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Bart A. J. A. van Oirschot
- Department of Dentistry – Regenerative Biomaterials, Radboud University Medical Centre, Philips van Leydenlaan 25, 6525 EX Nijmegen, The Netherlands
| | - Harry van Goor
- Department of Surgery (Route 618), Radboud University Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands
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Pangal DJ, Kugener G, Zhu Y, Sinha A, Unadkat V, Cote DJ, Strickland B, Rutkowski M, Hung A, Anandkumar A, Han XY, Papyan V, Wrobel B, Zada G, Donoho DA. Expert surgeons and deep learning models can predict the outcome of surgical hemorrhage from 1 min of video. Sci Rep 2022; 12:8137. [PMID: 35581213 PMCID: PMC9114003 DOI: 10.1038/s41598-022-11549-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 04/18/2022] [Indexed: 01/28/2023] Open
Abstract
Major vascular injury resulting in uncontrolled bleeding is a catastrophic and often fatal complication of minimally invasive surgery. At the outset of these events, surgeons do not know how much blood will be lost or whether they will successfully control the hemorrhage (achieve hemostasis). We evaluate the ability of a deep learning neural network (DNN) to predict hemostasis control ability using the first minute of surgical video and compare model performance with human experts viewing the same video. The publicly available SOCAL dataset contains 147 videos of attending and resident surgeons managing hemorrhage in a validated, high-fidelity cadaveric simulator. Videos are labeled with outcome and blood loss (mL). The first minute of 20 videos was shown to four, blinded, fellowship trained skull-base neurosurgery instructors, and to SOCALNet (a DNN trained on SOCAL videos). SOCALNet architecture included a convolutional network (ResNet) identifying spatial features and a recurrent network identifying temporal features (LSTM). Experts independently assessed surgeon skill, predicted outcome and blood loss (mL). Outcome and blood loss predictions were compared with SOCALNet. Expert inter-rater reliability was 0.95. Experts correctly predicted 14/20 trials (Sensitivity: 82%, Specificity: 55%, Positive Predictive Value (PPV): 69%, Negative Predictive Value (NPV): 71%). SOCALNet correctly predicted 17/20 trials (Sensitivity 100%, Specificity 66%, PPV 79%, NPV 100%) and correctly identified all successful attempts. Expert predictions of the highest and lowest skill surgeons and expert predictions reported with maximum confidence were more accurate. Experts systematically underestimated blood loss (mean error - 131 mL, RMSE 350 mL, R2 0.70) and fewer than half of expert predictions identified blood loss > 500 mL (47.5%, 19/40). SOCALNet had superior performance (mean error - 57 mL, RMSE 295 mL, R2 0.74) and detected most episodes of blood loss > 500 mL (80%, 8/10). In validation experiments, SOCALNet evaluation of a critical on-screen surgical maneuver and high/low-skill composite videos were concordant with expert evaluation. Using only the first minute of video, experts and SOCALNet can predict outcome and blood loss during surgical hemorrhage. Experts systematically underestimated blood loss, and SOCALNet had no false negatives. DNNs can provide accurate, meaningful assessments of surgical video. We call for the creation of datasets of surgical adverse events for quality improvement research.
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Affiliation(s)
- Dhiraj J Pangal
- Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Guillaume Kugener
- Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Yichao Zhu
- Viterbi School of Engineering, University of Southern California, Los Angeles, CA, USA
| | - Aditya Sinha
- Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Vyom Unadkat
- Viterbi School of Engineering, University of Southern California, Los Angeles, CA, USA
| | - David J Cote
- Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Ben Strickland
- Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Martin Rutkowski
- Department of Neurosurgery, Medical College of Georgia, Augusta, GA, USA
| | - Andrew Hung
- Center for Robotic Simulation and Education, USC Institute of Urology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Animashree Anandkumar
- Department of Computer Science + Mathematics, California Institute of Technology, Pasadena, CA, USA
- Nvidia Corp., Santa Clara, CA, USA
| | - X Y Han
- Department of Operations Research and Information Engineering, Cornell University, Ithaca, NY, USA
| | - Vardan Papyan
- Department of Mathematics, University of Toronto, Toronto, ON, Canada
| | - Bozena Wrobel
- Department of Otolaryngology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Gabriel Zada
- Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Daniel A Donoho
- Division of Neurosurgery, Center for Neuroscience, Children's National Hospital, Washington, DC, 20010, USA.
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10
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James J, Irace AL, Gudis DA, Overdevest JB. Simulation training in endoscopic skull base surgery: A scoping review. World J Otorhinolaryngol Head Neck Surg 2022; 8:73-81. [PMID: 35619934 PMCID: PMC9126166 DOI: 10.1002/wjo2.11] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 09/22/2021] [Indexed: 01/16/2023] Open
Abstract
Objective Methods Results Conclusions
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Affiliation(s)
- Joel James
- City University of New York School of Medicine New York New York USA
| | - Alexandria L. Irace
- Department of Otolaryngology‐Head and Neck Surgery, Columbia University Vagelos College of Physicians and Surgeons Columbia University Irving Medical Center, New York‐Presbyterian Hospital New York New York USA
| | - David A. Gudis
- Department of Otolaryngology‐Head and Neck Surgery, Columbia University Vagelos College of Physicians and Surgeons Columbia University Irving Medical Center, New York‐Presbyterian Hospital New York New York USA
| | - Jonathan B. Overdevest
- Department of Otolaryngology‐Head and Neck Surgery, Columbia University Vagelos College of Physicians and Surgeons Columbia University Irving Medical Center, New York‐Presbyterian Hospital New York New York USA
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11
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Masalha MA, VanKoevering KK, Latif OS, Powell AR, Zhang A, Hod KH, Prevedello DM, Carrau RL. Simulation of Cerebrospinal Fluid Leak Repair Using a 3-Dimensional Printed Model. Am J Rhinol Allergy 2021; 35:802-808. [PMID: 33745321 DOI: 10.1177/19458924211003537] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Acquiring proficiency for the repair of a cerebrospinal fluid (CSF) leak is challenging in great part due to its relative rarity, which offers a finite number of training opportunities. OBJECTIVE The purpose of this study was to evaluates the use of a 3-dimensional (3D) printed, anatomically accurate model to simulate CSF leak closure. METHODS Volunteer participants completed two simulation sessions. Questionnaires to assess their professional qualifications and a standardized 5-point Likert scale to estimate the level of confidence, were completed before and after each session. Participants were also queried on the overall educational utility of the simulation. RESULTS Thirteen otolaryngologists and 11 neurosurgeons, met the inclusion criteria. A successful repair of the CSF leak was achieved by 20/24 (83.33%), and 24/24 (100%) during the first and second simulation sessions respectively (average time 04:04 ± 1.39 and 02:10 ± 01:11). Time-to-close-the-CSF-leak during the second session was significantly shorter than the first (p < 0.001). Confidence scores increased across the training sessions (3.3 ± 1.0, before the simulation, 3.7 ± 0.6 after the first simulation, and 4.2 ± 0.4 after the second simulation; p < 0.001). All participants reported an increase in confidence and believed that the model represented a valuable training tool. CONCLUSIONS Despite significant differences with varying clinical scenarios, 3D printed models for cerebrospinal leak repair offer a feasible simulation for the training of residents and novice surgeons outside the constrictions of a clinical environment.
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Affiliation(s)
- Muhamed A Masalha
- Department of Otolaryngology, Head and Neck Surgery, Emek Medical Center, Afula, Israel.,Faculty of Medicine, Technion Institute of Technology, Haifa, Israel.,Department of Academy and Research, Assuta Medical Center, Tel Aviv, Israel.,Faculty of Medicine, Ben Gurion University, Tel Aviv, Israel
| | - Kyle K VanKoevering
- Department of Otolaryngology-Head and Neck Surgery, Michigan University, Ann Arbor, Michigan
| | - Omar S Latif
- Faculty of Medicine, The Ohio State University, Columbus, Ohio
| | - Allison R Powell
- Department of Otolaryngology-Head and Neck Surgery, Michigan University, Ann Arbor, Michigan
| | - Ashley Zhang
- Department of Otolaryngology-Head and Neck Surgery, Michigan University, Ann Arbor, Michigan
| | - Keren H Hod
- Department of Academy and Research, Assuta Medical Center, Tel Aviv, Israel.,Faculty of Medicine, Ben Gurion University, Tel Aviv, Israel
| | - Daniel M Prevedello
- Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio.,Department of Neurological Surgery, The James Cancer Hospital at The Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Ricardo L Carrau
- Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio.,Department of Neurological Surgery, The James Cancer Hospital at The Wexner Medical Center at The Ohio State University, Columbus, Ohio
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12
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Training and Surgical Simulation in Skull Base Surgery: a Systematic Review. CURRENT OTORHINOLARYNGOLOGY REPORTS 2020. [DOI: 10.1007/s40136-020-00280-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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13
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Mattavelli D, Ferrari M, Rampinelli V, Schreiber A, Buffoli B, Deganello A, Rodella LF, Fontanella MM, Nicolai P, Doglietto F. Development and validation of a preclinical model for training and assessment of cerebrospinal fluid leak repair in endoscopic skull base surgery. Int Forum Allergy Rhinol 2019; 10:89-96. [PMID: 31574591 DOI: 10.1002/alr.22451] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 08/21/2019] [Accepted: 09/13/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND Achieving an effective endoscopic skull base reconstruction in case of large dural defects requires specific training and can be extremely challenging. The aim of this study was to describe the development and validation of a preclinical model for cerebrospinal fluid (CSF) leak repair, which can be used for training and to test the mechanical efficacy of endoscopic skull base reconstruction. METHODS Eleven fresh-frozen cadaver heads were dissected. A catheter was inserted in the subdural space via a cervical access, which was sealed with mastic; a vertical graduated tube connected to the catheter measured intracranial pressure (ICP), while stained water was injected intracranially. After endoscopic skull base reconstruction was performed, an expert surgeon assessed its efficacy. ICP was then gradually increased until a leak was evident and CSF leak pressure value was recorded. The correlation between subjective and quantitative evaluations was investigated through Pearson and Spearman correlation tests. RESULTS The model was successfully tested in 11 specimens. A single, large dural defect was created in each model (transplanum-transtuberculum = 4; transplanum-transtuberculum-transsellar = 3; transclival = 3; transcribriform-transplanum = 1). Skull base reconstruction always comprised a rigid buttress with temporal fascia and/or fat. The CSF leak pressure ranged from 4 to 110 cmH2 O. The correlation between expert subjective and quantitative assessment of skull base reconstruction mechanical efficacy was high (r = 0.7; rs = 0.7; p = 0.010 and p = 0.006, respectively). CONCLUSION This preclinical model is simple, easily reproducible, and effective in simulating an intraoperative leak and objectively measures the CSF leak pressure point of a skull base reconstruction.
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Affiliation(s)
- Davide Mattavelli
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marco Ferrari
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Vittorio Rampinelli
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Alberto Schreiber
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Barbara Buffoli
- Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Alberto Deganello
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Luigi F Rodella
- Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Marco M Fontanella
- Unit of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Piero Nicolai
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Francesco Doglietto
- Unit of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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14
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Buchanan IA, Min E, Pham MH, Donoho DA, Bakhsheshian J, Minneti M, Zada G, Giannotta SL, Hsieh PC, Liu JC. Simulation of Dural Repair in Minimally Invasive Spine Surgery With the Use of a Perfusion-Based Cadaveric Model. Oper Neurosurg (Hagerstown) 2019; 17:616-621. [DOI: 10.1093/ons/opz041] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 02/14/2019] [Indexed: 01/22/2023] Open
Abstract
Abstract
BACKGROUND AND IMPORTANCE
In an era of curtailed work hours and concerns over achieving technical proficiency in the repertoire of procedures necessary for independent practice, many residencies have turned to model simulation as an educational adjunct. Cerebrospinal fluid (CSF) leak repair after inadvertent durotomy in spine surgery is a fundamental skillset for any spine surgeon. While primary closure with suture is not always necessary for small durotomies, larger defects, on the other hand, must be repaired. However, the dire consequences of inadequate repair dictate that it is generally performed by the most experienced surgeon. Few intraoperative opportunities, therefore, exist for CSF leak repair by trainees.
OBJECTIVE
To simulate dural repair in spine surgery using minimal-access techniques.
METHODS
A cohort of 8 neurosurgery residents was evaluated on their durotomy repair efforts in a perfusion-based cadaveric model.
RESULTS
Study participants demonstrated consistent improvement across trials, with a significant reduction in closure times between their initial (12 min, 7 sec ± 4 min, 43 sec) and final attempts (7 min, 4 sec ± 2 min, 6 sec; P = .02). Moreover, all trainees—irrespective of postgraduate year—were able to accomplish robust dural closures resistant to simulated Valsalva maneuvers. Participants reported high degrees of model realism and exhibited significant increases in postprocedure confidence scores.
CONCLUSION
Our results support use of perfusion-based simulation models as a complement to neurosurgery training, as it affords unrestricted opportunities for honing psychomotor skillsets when resident learning is increasingly being challenged by work-hour limitations and stricter oversight in the context of value-based healthcare.
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Affiliation(s)
- Ian A Buchanan
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Elliot Min
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Martin H Pham
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Daniel A Donoho
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Joshua Bakhsheshian
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Michael Minneti
- Department of General Surgery, University of Southern California, Los Angeles, California
| | - Gabriel Zada
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Steven L Giannotta
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Patrick C Hsieh
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - John C Liu
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
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15
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Innovative real CSF leak simulation model for rhinology training: human cadaveric design. Eur Arch Otorhinolaryngol 2018; 275:937-941. [DOI: 10.1007/s00405-018-4902-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 02/05/2018] [Indexed: 01/16/2023]
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