Academic Stress Assessment Using Virtual Reality as an Educational Tool in Spine Surgery

Introduction: The evaluation of academic stress in medical students and residents is a topic of significant interest, given the considerable challenges they face during their learning process with traditional teaching methods. The use of technologies like virtual reality presents an opportunity to enhance their skills through simulations and training. The main objective of this study is to qualitatively assess the stress levels experienced by medical students and residents by integrating virtual reality into their current learning methods, aiming to improve their ability to manage stressors in their practice. Material and Methods: A questionnaire was conducted with 12 medical students and 12 Traumatology and orthopedics residents. The purpose of the questionnaire was to evaluate the levels of academic stress using the SISCO inventory. The stress levels were calculated by transforming average values into percentages, and the following criteria were assigned: 0 to 33% for Mild Stress, 34 to 66% for Moderate Stress, and 67 to 100% for Deep Stress. Then, a virtual reality class focused on spine surgery was provided. Both medical students and residents were trained using the Non Nocere SharpSurgeon software platform and Oculus Quest 2 virtual reality glasses. At the end of the session, a second questionnaire related to the practice with virtual reality was conducted with the same evaluation criteria and a comparative analysis was carried out. Results: 12 undergraduate students from Hospital Angeles Mexico, CDMX and 12 traumatology and orthopedics residents at Hospital Santa Fe, Bogota were evaluated. The students in CDMX reported an average qualitative stress of 28.50% during habitual practices, which decreased to an average of 14.67% after virtual reality practice. Residents in Bogotá experienced an average qualitative stress of 30.50% with their current learning methods but this reduced to an average of 13.92% after using virtual reality. These findings indicate that the use of virtual reality has a positive impact on reducing stress levels qualitatively. Conclusions: The use of virtual reality as a learning method for medical students and residents qualitatively improves stress levels. Further studies are required to define the potential uses of Virtual Reality to improve learning methods and emotional state in medical students and residents and for a quantitative assessment to validate the training as certified learning methods.

Background,techniques,applications,current trends,and future directions of minimally invasive endoscopic spine surgery:A review of literature

Across many of the surgical specialties,the use of minimally invasive techniques that utilize indirect visualization has been increasingly replacing traditional techniques which utilize direct visualization.Arthroscopic surgery of the appendicular skeleton has evolved dramatically and become an integral part of musculoskeletal surgery over the last several decades,allowing surgeons to achieve similar or better outcomes,while reducing cost and recovery time.However,to date,the axial skeleton,with its close proximity to critical neural and vascular structures,has not adopted endoscopic techniques at as rapid of a rate.Over the past decade,increased patient demand for less invasive spine surgery combined with surgeon desire to meet these demands has driven significant evolution and innovation in endoscopic spine surgery.In addition,there has been an enormous advancement in technologies that assist in navigation and automation that help surgeons circumvent limitations of direct visualization inherent to less invasive techniques.There are currently a multitude of endoscopic techniques and approaches that can be utilized in the treatment of spine disorders,many of which are evolving rapidly.Here we present a review of the field of endoscopic spine surgery,including the background,techniques,applications,current trends,and future directions,to help providers gain a better understanding of this growing modality in spine surgery.

Diagnostic approaches for pancreatic tuberculosis

To the Editor:Pancreatic tuberculosis refers to tuberculosis of pancreas and peripancreatic lymph nodes due to both conditions having similar clinical manifestations and therapeutic regimens[1,2].It is a rare entity worldwide,which is often shown as mass and treated by the unnecessary surgery due to misdiagnosis as pancreatic malignancy[1,2].

Successful surgical treatment of bronchopleural fistula caused by severe pulmonary tuberculosis:A case report and review of literature

BACKGROUND Bronchopleural fistula(BPF)is a relatively rare,but severe complication of pulmonary tuberculosis.It is associated with significant mortality;however,its management remains a major therapeutic challenge.CASE SUMMARY We present a 24-year-old man with BPF resulting from severe pulmonary tuberculosis combined with mixed infections.The damaged right upper lobe and concomitant empyema were demonstrated via computed tomography.After undergoing open-window thoracostomy and tuberculosis treatment for 4 mo,decortication and right upper lobectomy were subsequently performed,leading to the resolution of tuberculosis and other concurrent pulmonary infections.Followup,6 mo after surgery,failed to reveal any evidence of infection recurrence resulting in a good prognosis.CONCLUSION The disease course of tuberculous BPF is particularly challenging.Surgical intervention serves as an effective and safe therapeutic strategy for BPF.

Multitrack and multianchor point screw technique combined with the Wiltse approach for lesion debridement for lumbar tuberculosis

BACKGROUND The incidence of lumbar tuberculosis is high worldwide,and effective treatment is a continuing problem.AIM To study the safety and efficacy of the multitrack and multianchor point screw technique combined with the contralateral Wiltse approach for lesion debridement to treat lumbar tuberculosis.METHODS The C-reactive protein(CRP)level,erythrocyte sedimentation rate(ESR),visual analogue scale(VAS)score,oswestry disability index(ODI)and American Spinal Injury Association(ASIA)grade were recorded and analysed pre-and postoperatively.RESULTS The CRP level and ESR returned to normal,and the VAS score and ODI were decreased at 3 mo postoperatively,with significant differences compared with the preoperative values(P<0.01).Neurological dysfunction was relieved,and the ASIA grade increased,with no adverse events.CONCLUSION The multitrack,multianchor point screw fixation technique combined with the contralateral Wiltse approach for debridement is an effective and safe method for the treatment of lumbar tuberculosis.

Abdominal tuberculosis: Is there a role for surgery?

It is important that surgeons are familiar with the various manifestations of tuberculosis(TB). Although TB has been declining in incidence in the developed world, itremains an important problem in endemic areas of the developing world. The aim of the review was to elucidate the natural history and characteristics of abdominal TB and ascertain the indications for surgery. TB can affect the intestine as well as the peritoneum and the most important aspect of abdominal TB is to bear in mind the diagnosis and obtain histological evidence. Abdominal TB is generally responsive to medical treatment, and early diagnosis and management can prevent unnecessary surgical intervention. Due to the challenges of early diagnosis, patients should be managed in collaboration with a physician familiar with anti-tuberculous therapy. An international expert consensus should determine an algorithm for the diagnosis and multidisciplinary management of abdominal TB.

Effect of cervical spine surgery on the biomechanics of the cervical spine

In clinical practice,cervical spine surgery inevitably alters the original physiological structure of the cervical spine,thus causing changes in the original biomechanical properties of the cervical spine.The biomechanical properties of the cervical spine are particularly significant as it is an essential structure that supports the head and connects the trunk.Different cervical spine surgery options can have different effects on the biomechanics of the cervical spine.Therefore,this review will discuss recent research advances on the effects of cervical spine surgery on cervical spine biomechanics.We hope that this review will provide some theoretical basis for future studies on the biomechanical effects of cervical spine surgery on the cervical spine.

Demineralized Bone Matrix Fibers plus Allograft Bone for Multilevel Posterolateral Spine Fusion: A Game Changer?

Introduction: While autograft bone is the gold standard for multilevel posterolateral lumbar fusion, bone substitutes and graft extenders such as allograft bone, ceramics and demineralized bone matrix (DBM) have been used to avoid the morbidity and insufficient quantity associated with harvesting autologous bone. The primary objective of this retrospective study was to determine whether, in patients with increased risk of operative nonunion related to multilevel fusion, adding DBM fibers to mineralized bone allograft resulted in better fusion than using allograft alone. The secondary objectives were to evaluate how adding DBM fibers affects functional disability, low back pain, intraoperative blood loss and the nonunion rate. Methods: This retrospective study involved a chart review of consecutive patients who underwent multilevel lumbar spinal fusion and were operated on by a single surgeon. The patients were divided into two groups: 14 patients received mineralized bone allograft (control group) and 14 patients received a combination of mineralized bone allograft and DBM (experimental group). Patients were reviewed at a mean of 16.4 ± 2.2 months after surgery at which point CT scans were analyzed to determine whether fusion had occurred;Oswestry disability index (ODI) and pain were also evaluated. Results: A mean of 5 levels [min 2, max 13] were fused in these patients. Posterolateral fusion as defined by the Lenke classification was not significantly different between groups. The experimental DBM group had a significantly better composite fusion score than the control group (P Discussion: Adding DBM fibers to allograft bone during multilevel posterolateral spinal fusion was safe and produced better composite fusion than using allograft only as an autograft extender.

French Spine Surgery Society guidelines for management of spinal surgeries during COVID-19 pandemic

Since the outbreak of coronavirus disease 2019(COVID-19)in December 2019 in China,various measures have been adopted in order to attenuate the impact of the virus on the population.With regard to spine surgery,French physicians are devoted to take place in the national plan against COVID-19,the French Spine Surgery Society therefore decided to elaborate specific guidelines for management of spinal disorders during COVID-19 pandemic in order to prioritize management of patients.A three levels stratification was elaborated with Level I:Urgent surgical indications,Level II:Surgical indications associated to a potential loss of chance for the patient and Level III:Non-urgent surgical indications.We also report French experience in a COVID-19 cluster region illustrated by two clinical cases.We hope that the guidelines formulated by the French Spine Surgery Society and the experience of spine surgeons from a cluster region will be helpful in order optimizing the management of patients with urgent spinal conditions during the pandemic.

C1-C2 Pott’s Disease, a Rare Location of Spine Tuberculosis

The authors report a new case of spine tuberculosis of C1-C2 occurred in a 58-year-old negative HIV patient that was responsible of inflammatory cervical pain with multidirectional stiffness and complicated by spastic quadriplegia. The diagnosis was made on the basis of presumptive elements, including cervical spinal CT scan, which showed atlan-to-axial subluxation (C1-C2) with destruction of the odontoid apophysis and lateral mass of the atlas and favorable evolution under specific antibiotic treatment with ethambutol, isoniazid, rifampicin, pyrazinamide and immobilization with brace cast, despite the absence of bacteriological and anatomo-pathological evidence of certainty. The evolution has been favorable, with the disappearance of cervical pain, progressive motor recovery and resumption of autonomy of walking.

Tuberculosis of the Spine (L5, S1) Secondary to Scrofuloderma with Viral Warts in a 15-Year-Old Male

We report this case of a 15-year-old male who presented to the children outpatient clinic (CHOP) of Abia State University Teaching Hospital (ABSUTH), Aba on the 5th of November 2015. He had tuberculosis (TB) of the skin (scrofuloderma) which was not diagnosed and had received treatment other than anti-TB medication. He now presented 9 years after with multiple body discharging sinuses, cicatricial skin lesions, tuberculosis of the spine (L5, S1) with contracture of the Achilles Tendon and genital warts. Subsequent treatment with full anti-TB drugs led to resolution of his illness. A higher index of suspicion is required for early diagnosis of extrapulmonary TB. Prompt and adequate treatment with anti-TB medication ensures cure in such cases. Appropriate control program is also known to improve the outcome and reduce sequelae.

Positioning patients for spine surgery: Avoiding uncommon position-related complications

Positioning patients for spine surgery is pivotal for optimal operating conditions and operative-site exposure. During spine surgery, patients are placed in positions that are not physiologic and may lead to complications. Perioperative peripheral nerve injury(PPNI) and postoperative visual loss(POVL) are rare complications related to patient positioning during spine surgery that result in significant patient disability and functional loss. PPNI is usually due to stretch or compression of the peripheral nerve. PPNI may present as a brachial plexus injury or as an isolated injury of single nerve, most commonly the ulnar nerve. Understanding the etiology, mechanism and pattern of injury with each type of nerve injury is important for the prevention of PPNI. Intraoperative neuromonitoring has been used to detect peripheral nerve conduction abnormalities indicating peripheral nerve stress under general anesthesia and to guide modification of the upper extremity position to prevent PPNI. POVL usually results in permanent visual loss. Most cases are associated with prolonged spine procedures in the prone position under general anesthesia. The most common causes of POVL after spine surgery are ischemic optic neuropathy and central retinal artery occlusion. Posterior ischemic opticneuropathy is the most common cause of POVL after spine surgery. It is important for spine surgeons to be aware of POVL and to participate in safe, collaborative perioperative care of spine patients. Proper education of perioperative staff, combined with clear communication and collaboration while positioning patients in the operating room is the best and safest approach. The prevention of uncommon complications of spine surgery depends primarily on identifying high-risk patients, proper positioning and optimal intraoperative management of physiological parameters. Modification of risk factors extrinsic to the patient may help reduce the incidence of PPNI and POVL.

Perioperative visual loss after spine surgery

Perioperative visual loss(POVL) is an uncommon, but devastating complication that remains primarily associated with spine and cardiac surgery. The incidence and mechanisms of visual loss after surgery remain difficult to determine. According to the American Society of Anesthesiologists Postoperative Visual Loss Registry, the most common causes of POVL in spine procedures are the two different forms of ischemic optic neuropathy: anterior ischemic optic neuropathy and posterior ischemic optic neuropathy, accounting for 89% of the cases. Retinal ischemia, cortical blindness, and posterior reversible encephalopathy are also observed, but in a small minority of cases. A recent multicenter case control study has identified risk factors associated with ischemic optic neuropathy for patients undergoing prone spinal fusion surgery. These include obesity, male sex, Wilson frame use, longer anesthetic duration, greater estimated blood loss, and decreased percent colloid administration. These risk factors are thought to contribute to the elevation of venous pressure and interstitial edema, resulting in damage to the optic nerve by compression of the vessels that feed the optic nerve, venous infarction or direct mechanical compression. This review will expand on these findings as well as the recently updated American Society of Anesthesiologists practice advisory on POVL. There are no effectivetreatment options for POVL and the diagnosis is often irreversible, so efforts must focus on prevention and risk factor modification. The role of crystalloids versus colloids and the use of α-2 agonists to decrease intraocular pressure during prone spine surgery will also be discussed as a potential preventative strategy.

Pulmonary complications after spine surgery

Spine surgery is one of the fastest growing branches of orthopedic surgery. Patients often present with a relatively high acuity and, depending on surgical approach, morbidity and mortality can be comparatively high. Among the most prevalent and most frequently fatalitybound perioperative complications are those affecting the pulmonary system; evidence of clinical or subclinical lung injury triggered by spine surgical procedures is emerging. Increasing burden of comorbidity among the patient population further increases the likelihood of adverse outcome. This review is intended to give an overview over some of the most important causes of pulmonary complications after spine surgery, their pathophysiology and possible ways to reduce harm associated with those conditions. We discuss factors surrounding surgical trauma, timing of surgery, bone marrow and debris embolization, transfusion associated lung injury, and ventilator associated lung injury.

Comparative induction of controlled circulation by magnesium and remifentanil in spine surgery

AIM: To evaluate the efficacy of magnesium sulfate(MGS) in comparison with remifentanil for induction of relative hypotension in posterior fusion of spine(PSF).METHODS: In this randomized clinical trial, 40 patients with the American Society of Anesthesiologists Ⅰ and Ⅱ physical status undergoing lumbar PSF were randomized to receive remifentanil(REM) 0.15 μg/kg or MGS 50 mg/kg for controlled hypotension. The administering anesthesiologist was blinded to the medication. Continuous infusion was maintained at a fixed volume rate to deliver precalculated doses of either study drugs. All other aspects of anesthesia and surgery were similar in the two groups. The target mean arterial pressure(MAP) range used in this study was 60-70 mm Hg. In the course of surgery, the hemodynamic variables, volumeof blood loss, urine output, fluid intake and surgeon's satisfaction were recorded. Data was analyzed with SPSS version 13.0 and P values less than 0.05 were considered significant.RESULTS: Twenty patients in the MGS group and 19 patients in the REM group were studied. There was no difference between the two groups in the hemodynamic variables, blood loss, urine output, fluid requirement and surgeon's satisfaction for exposure. The target MAP was achieved in 75% of Mg and 58% of remifentanil groups. Although a higher number of patients in the REM group required nitroglycerin(42.1%) to reach the target MAP than those in the MGS group(25%), this difference was not statistically significant(P = 0.32).CONCLUSION: Our findings showed that in patients undergoing lumbar PSF surgery, remifentanil and MGS have a similar hypotensive effect and comparable amount of blood loss without any significant adverse effects.

Percutaneous Endoscopic Lumbar Spine Surgery for Lumbar Disc Herniation and Lumbar Spine Stenosis: Emphasizing on Clinical Outcomes of Transforaminal Technique

Lumbar Disc Herniation and Lumbar Spine Stenosis are the most common spine diseases which are mainly due to age related Spine degeneration. Diagnosis of both Lumbar Disc Herniation and Lumbar Spine Stenosis depends on clinical findings as well as radiological investigations. Treatment of choice of these conditions is on the basis of the patient conditions. Surgical treatment is the option only when the conservative treatment does not improve the patient’s clinical condition. Advancement and improvement of the technology have resulted in the traditional open surgical treatment into minimal invasive surgery. Intervention of the different surgical instruments with expert spinal surgeons had made percutaneous endoscopic lumbar Spine surgery as one of the preferred choices of surgery for treating Lumbar Disc Herniation and Lumbar Spine Stenosis. The concept of percutaneous endoscopic surgery for lumbar region is to provide surgical options without producing iatrogenic morbidity associated with the open surgical procedures. Conventionally, there are different approaches/techniques for Percutaneous Endoscopic Lumbar Spine Surgery, but in this review we are mainly focusing on the Transforaminal Technique. Regarding the Lumbar Disc Herniation treatment with transforaminal approach, a number of articles have been published due to which we mainly focused on those articles which were published after 2009 onwards. While fewer articles related to Lumbar Spine Stenosis treatment with Transforaminal approach were found, we tried to brief out all those articles. On the basis of comparative study of different surgeries done for Lumbar Disc Herniation and Lumbar Spine Stenosis, Percutaneous Transforaminal endoscopic Lumbar Surgery provides a substantial benefit. Transforaminal approach for treating Lumbar Disc Herniation and Lumbar Spine Stenosis is safe and effective. The Percutaneous Transforaminal Endoscopic Lumbar Surgery has advantage as it is performed under local anesthesia with shorter length of hospitalization and early return to normal life. The clinical outcome of the patient that underwent Percutaneous Transforaminal Endoscopic Lumbar Surgery for Lumbar Disc Herniation and Lumbar Spine Stenosis is quite good in regard of its fewer complication and more benefits.

Perioperative outcomes in minimally invasive lumbar spine surgery: A systematic review

AIM: To compare minimally invasive(MIS) and open techniques for MIS lumbar laminectomy, direct lateral and transforaminal lumbar interbody fusion(TLIF) surgeries with respect to length of surgery, estimated blood loss(EBL), neurologic complications, perioperative transfusion, postoperative pain, postoperative narcotic use, and length of stay(LOS).METHODS: A systematic review of previously published studies accessible through Pub Med was performed. Only articles in English journals or published with English language translations were included. Level of evidence of the selected articles was assessed. Statistical data was calculated with analysis of variance with P < 0.05 considered statistically significant.RESULTS: A total of 11 pertinent laminectomy studies, 20 direct lateral studies, and 27 TLIF studies were found. For laminectomy, MIS techniques resulted in a significantly longer length of surgery(177.5 min vs 129.0 min, P = 0.04), shorter LOS(4.3 d vs 5.3 d, P = 0.01) and less perioperative pain(visual analog scale: 16 ± 17 vs 34 ± 31, P = 0.04). There is evidence of decreased narcotic use for MIS patients(postoperative intravenous morphine use: 9.3 mg vs 42.8 mg), however this difference is of unknown significance. Direct lateral approaches have insufficient comparative data to establish relative perioperative outcomes. MIS TLIF had superior EBL(352 mL vs 580 mL, P < 0.0001) and LOS(7.7 d vs 10.4 d, P < 0.0001) and limited data to suggest lower perioperative pain.CONCLUSION: Based on perioperative outcomes data, MIS approach is superior to open approach for TLIF. For laminectomy, MIS and open approaches can be chosen based on surgeon preference. For lateral approaches, there is insufficient evidence to find noninferior perioperative outcomes at this time.

Vitamin D and spine surgery

Vitamin D is crucial for musculoskeletal health, maintenance, and function. Vitamin D insufficiency is common among patients undergoing spine surgery and the ideal vitamin D level for spine surgery has yet to be investigated. There is a high prevalence of hypovitaminosis D in patients with musculoskeletal pain regardless of surgical intervention. With the frequency and costs of spine surgery increasing, it is imperative that efforts are continued to reduce the impact on patients and healthcare services. Studies into vitamin D and its associations with orthopaedic surgery have yielded alarming findings with regards to the prevalence of vitamin D deficiency. Importantly, altered vitamin D status also contributes to a wide range of disease conditions. Therefore, future investigations are still essential for better understanding the relationship between vitamin D and spine surgery outcomes. Whilst further research is required to fully elucidate the extent of the effects of hypovitaminosis D has on surgical outcomes, it is strongly advisable to reduce the impacts by appropriate vitamin D supplementation of deficient and at-risk patients.

Erector spinae plane block at lower thoracic level for analgesia in lumbar spine surgery: A randomized controlled trial

BACKGROUND Patients undergoing lumbar spine surgery usually suffer severe pain in the postoperative period.The erector spinae plane block(ESPB),first published in 2016,can anesthetize the ventral and dorsal rami of thoracic nerves and produce an extensive multi-dermatomal sensory block.AIM To assess whether bilateral ultrasound-guided ESPB at a lower thoracic level could improve pain control and quality of recovery in patients undergoing lumbar spine surgery.METHODS A total of 60 patients aged 18-80 years scheduled to undergo lumbar spine surgery with general anesthesia were randomly assigned to two groups:ESPB group(preoperative bilateral ultrasound-guided ESPB at T10 vertebral level)and control group(no preoperative ESPB).Both groups received standard general anesthesia.The main indicator was the duration to the first patient controlled intravenous analgesia(PCIA)bolus.RESULTS In the ESPB group,the duration to the first PCIA bolus was significantly longer than that in the control group(h)[8.0(4.5,17.0)vs 1.0(0.5,6),P<0.01],and resting and coughing numerical rating scale(NRS)scores at 48 h post operation were significantly lower than those in the control group(P<0.05).There was no significant difference between the two groups regarding resting and coughing NRS scores at 24 h post operation.Sufentanil consumption during the operation was significantly lower in the ESPB group than in the control group(P<0.01),while there was no significant difference between the two groups regarding morphine consumption at 24 or 48 h post operation.In the ESPB group,Modified Observer’s Assessment of Alertness/Sedation score within 20 min after extubation was higher and duration in the post-anesthesia care unit was shorter than those in the control group(P<0.01).CONCLUSION In patients undergoing lumbar spine surgery,ultrasound-guided ESPB at a lower thoracic level improves the analgesic effect,reduces opioid consumption,and improves postoperative recovery.