Stereotactic Surgery

Stereotactic or Stereotaxic Surgery . Neurosurgical technique that allows you to precisely locate a point within the cranial cavity. It requires the placement of an external structure (stereotaxic halo) that is fixed to the patient’s head and constitutes a frame of reference for orthogonal coordinates. It is useful for taking biopsies or for resecting small, deep lesions, and forms the basis for radiosurgery.

Summary

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  • 1 Background
  • 2 History in synthesis
  • 3 How it is done
  • 4 Cuban Stereotactic System
  • 5 Indications
  • 6 benefits
  • 7 Sources

Background

Neurosurgery has always considered the need for surgical access to deep areas of the brain, to provide solutions to innumerable situations arising from various diseases that can affect the nervous system. Therefore, a great effort has been made in the design of methodologies and equipment that, in the end, have allowed it with very high precision, choosing the shortest path and with the minimum alteration of brain structures.

Scheme of the stereotaxic frame

In order to achieve this, stereotaxic systems, more or less complex systems, in the form of a cube or sphere, were attached to the patient’s skull. Its operation basically consists of adapting these devices to the patient’s head (usually with local anesthesia) and then carrying out neuroimaging studies (X-rays, CT, MRI or Arteriography). In this way, coordinates (in the three axes of space) of the area within the brain to be accessed (target point) can be obtained. This guarantees that any material, object or type of energy is subsequently sent to said target, with great security.

History in synthesis

  • Born in 1906 by Robert Clarke and Victor Horsley .
  • Mussen in 1918 designed the first apparatus.
  • Kirscher in 1933 developed an instrument for gasserian coagulation.
  • 1947 Spiegel and Wycis report first human operation.
  • Emergence of new devices Leksell and Riechert Mundinger (1949-1955)
  • 1958 Mundinger introduces stereotaxic biopsy and interstitial brachytherapy.
  • Technique development (CAT and NMR).
  • Cuba 1955 Dr Meléndez.
  • Extension to other neurosurgeons.
  • 1970 Renaissance at the INNC.
  • 1990 Incorporation to HHAmeijeiras.
  • 1997 Development of the Cuban framework Estereoflex.

The first stereotactic apparatus was developed in 1906 by Henry Clarke and Victor Horsley to conduct small animal studies. However, it was not adapted for use in humans until 1947 (Spiegel and Wycis), due to the difficulty in visualizing the cranioencephalic structures.. These latter authors, at the beginning of stereotaxic surgery, used this technique in patients with severe psychiatric disorders. They held the patient’s head in a plaster cast, injected contrast into the cerebral ventricles, and performed radiographs to locate deep brain nuclei believed to be responsible for these disorders. Later, this technique was also applied to interrupt the pain pathways, treat uncontrollable movements or epilepsy and aspirate the contents of the cystic lesions.

In Sweden , almost almost simultaneously, Leksell developed his own stereotaxic system in 1949. His apparatus consisted of a cube that was attached to the patient’s skull and had a movable arch, which in turn was attached to the cube. A probe was inserted into the arch and reached the selected point. Even today the use of its Stereotaxic Guide persists, with slight adaptations of the original, being the most widely accepted and used in the neurosurgical environment.

Another important milestone marked by Leksell was the conception and design of radiosurgery techniques, by means of which multiple radiation beams converge in an injury or brain nucleus that one wishes to destroy, without damaging the rest of the brain parenchyma.

In France , in the 1950s, Talairach also designed another system that allowed several electrodes to be inserted simultaneously and in parallel in the cerebral cortex, to study patients with uncontrollable epilepsy.

These and other authors designed some Stereotaxic Atlases, which show millimeter cuts of the brain, which made it possible to recognize the brain structures that you want to access.

In the 1960s, the stereotaxic technique was generalized and many surgical procedures were performed, mainly to treat uncontrollable movements (such as Parkinson’s disease) and intractable pain or epilepsy. During the 1970s, however, its use decreased significantly with the appearance of other treatments for Parkinson’s disease.

So far, Stereotaxic Neurosurgery walked almost independently from General Neurosurgery, due to its different surgical techniques and diseases to be treated. But in the 1980s, the use of stereotaxy reappeared more strongly, due to advances in imaging techniques such as Computerized Axial Tomography (CAT) and magnetic resonance imaging (MRI). With these techniques, small intracerebral lesions such as tumors, cysts, and vascular malformations can be visualized, so general neurosurgeons began to understand, first, and then use stereotaxic concepts and equipment to access these lesions and proceed with their removal.

Today, with stereotaxic surgery, deep lesions that were previously not possible can be located and addressed to take a biopsy, remove them or empty their cystic content, all thanks to a combined stereotaxic-microsurgical procedure. Or proceed to its destruction by means of radiosurgical techniques.

How it is performed

This technique is usually performed under local anesthesia and consists of placing the stereotaxic frame attached to the head at the 4 points where it is attached to the skull. Panels or locators bearing radiopaque markings are placed on the frame and will later appear in radiological studies.

Then the most suitable radiological study is carried out for each patient (the most common is the CT). In the radiological examination, the lesion or the target point to which you want to access is indicated and the markers located in the guide will be displayed, which allow calculating the coordinates of the point in the three axes of space.

Subsequently, the patient goes to the operating room, where an incision is made in the skin and a small perforation of the skull, also under local anesthesia. An arc with the coordinates obtained in the radiological study is placed on the stereotaxic frame and a probe or cannula is attached to it, which is to be directed to the previously selected point.

This procedure alone requires an average hospital stay of 24 or 48 hours after being performed. But this will depend, of course, on the reason for the stereotaxic surgery.

Cuban Stereotactic System

  • National experience in Parkinson’s disease surgery.

In the year 1954-55, in the Neurosurgery Service of the General University Hospital Calixto García Iñiguez, directed by Dr. Ramírez Corría, an exchange was made with Dr. Cooper, after his first experiences in the treatment of Parkinson’s disease. In 1955, Dr. Jesús Eusebio Meléndez traveled to New York and worked with Dr. Cooper in performing the stereotactic pallidotomy. Subsequently, Cooper’s stereotactic system is acquired and this surgical technique is introduced in the Neurosurgery Service of the “Calixto García Iñiguez” Hospital.

The group of neurosurgeons who participated in the introduction of stereotaxis in Cuba, was also made up of Drs. Jorge Picasa Benitez, Rafael Gallardo, Bradshaw and Lore de Mora, Prof. Ramírez Corría, Prof. Jesús E. Meléndez and Prof. Rafael Gallant

A first presentation of the results was made in 17 patients operated on in 1956. In 1968, Professor, Dr. Roger Figueredo received a training course in Stockholm (Sweden) with Dr. Lars Leksell, to carry out ventrolateral thalamotomy (VL) as a treatment for PD. In 1969, a Leksell variant D stereotactic system was acquired by the National Institute of Neurology and Neurosurgery (INN). In this way, VL Thalamotomy guided by pneumoventriculography and iodoventriculography began with the use of a stereotactic atlas of Tailarach and records of deep electrical activity. Thus restarting in the country, functional surgery in PD.

During this period, 50 patients with PD underwent surgery, participating in the application of these techniques: Drs: Pérez Lache, Humberto H. Zayas, Gil Marín and Lázaro Camblor. In the mid-1970s, stereotactic surgery was completely abandoned in the country.

On March 26, 1987, with the assistance of a large group of specialists and the advice of Drs. Madrazo and Drucker of the Autonomous University of Mexico, the first adrenal transplant in Cuba was performed on a patient with PD, followed by other 3 patients. On January 29, 1988, the first fetal tissue transplant was performed by the same group, until accumulating experience in a total of 39 patients.

In 1991 at the Iberolatinoamericano Center for Transplantation and Regeneration of the Nervous System, currently CIREN, the first unilateral stereotactic transplant with midbrain suspension was startedventral fetalis to 10 patients with PD and in 1992 bilateral stereotactic procedures were performed on 15 other patients. In January and October 1993, ablative functional surgery for PD was resumed (thalamotomy and pallidotomy), now guided by CT and with semi-microregisters. of deep electrical activity. This time there was the collaboration of the Professor. C. Ohye from Japan. Up to 1995, when the subthalamotomy was started, more than 100 proceeded to function, consolidating the experience of this group in functional surgery with recording of electrical activity. Currently, more than 1000 surgical interventions have been carried out by the stereotactic functional surgery group for movement disorders at CIREN.

Although it has been used since the late 1990s with excellent results, Estereoflex, its trade name, remains a technological novelty for its accuracy, easy handling, lightness and versatility. Created by specialists from the International Neurological Restoration Center (CIREN) and the Immunoassay Center, both located in the capital, this system allows the aforementioned pathologies to be tackled with the greatest benefits for the patient and the minimum risks.

“It is a system that guides the surgeon. It is integrated by the frame (which includes, among other parts, the ring that is fixed on the patient’s head and the arch through which the guide that allows measurements to be moved) and the software for surgical planning and recording of deep neural electrical activity when used in functional surgery ”, explained Dr. Iván García Maeso, CIREN Neurosurgeon.

Among the advantages of this technology in relation to similar in other countries, the specialist mentions its precision. “Functional surgery, above all, requires great rigor in calculations, which is why it was decided to include the sub-millimeter scale in the Cuban framework, which no others that are marketed in the world have.”

According to Dr. García Maeso, other characteristics of the system is that the skull can be accessed above or below (others also allow it, but many do not), the towers have various angles of movement, and the frame has on its front part Multiple interchangeable attachments to facilitate intubation anesthetic maneuvers.

Stereoflex is novel, furthermore, because the surgical planning software with Computerized Axial Tomography, Magnetic Resonance Imaging and Digital Subtraction Angiography achieves adequate image processing speeds and calculation accuracy, and requires only personal microcomputers.

On the other hand, specialists ensure that the software for recording and processing brain electrical activity, in addition to replacing expensive and complex equipment with a personal microcomputer, automates and facilitates the analysis of records.

With the aim of providing specialized medical assistance to all citizens, this technique gradually extends to other hospitals in the country. Thus, clinics in the provinces of Santiago de Cuba, Holguín, Camagüey, Cienfuegos and, soon, Villa Clara are already putting it into practice. In the capital, in addition to CIREN, they use it at the Hermanos Ameijeiras Hospital, the Institute of Neurology and Neurosurgery, the Center for Medical-Surgical Research (CIMEQ) and it is planned to introduce it at the Military Hospital Doctor Luis Díaz Soto, according to workers. Dr. Emilio Villa Acosta, executive deputy director of CIREN.

Beyond our borders, the effectiveness of this technology is also corroborated in the University Hospital of Santiago de Chile; in Spain, where they have the software for functional surgery installed, and it will be soon in Mexico, said Dr. Villa.

Stereotactic surgery is one of the numerous projects developed by the International Center for Neurological Restoration, an institution of great prestige inside and outside Cuba, conceived for basic-clinical research in the field of neuroscience, which works on the frontier of knowledge with a view to providing new treatments and diagnostic elements, in addition to providing specialized medical care for these diseases.

Indications

  • Cystic lesion evacuation.
  • Interstitial brachytherapy.
  • Abscess evacuation.
  • Hematoma evacuation.
  • Evacuation of cysts due to radionecrosis.
  • Targeted craniotomies.
  • Functional Surgery.
  • Pain surgery.
  • Support for neuroendoscopy.

Benefits

  • Decreases surgical time.
  • Exact method.
  • It allows intraoperative brachytherapy.
  • Low risk of morbidity and mortality.
  • It can sometimes be done under local anesthesia.
  • It allows the approach to deep injuries.
  • Allows accurate histological diagnosis
  • Easy to use after a workout.
  • They allow histopathological diagnosis through a minimally invasive procedure with access to almost any region of the brain, which in turn allows for more timely therapeutic decisions.
  • It offers a low morbidity and mortality rate.

 

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