Background: On February 6, 2015, the Supreme Court of Canada struck down the Criminal Code absolute prohibition on assisted dying, and in June 2016 the new law, Bill C-14, came into effect allowing for medical assistance in dying. We sought to determine the attitudes and opinions of Canadian neurosurgeons and orthopedic spine surgeons regarding MAID. Methods: A cross-sectional survey was sent out to members of the Canadian Spine Society (CSS), which included 21 questions pertaining to opinions regarding MAID. Responses were collected between May-June 2016. Results: A total of 51 surgeons responded to the survey, comprised of a mix of spine surgeons from across the country. The majority of surgeons supported MAID (62.8%), and right of physicians to participate (82.4%). Most surgeons supported the right to conscientious objection (90.1%), but also mandatory duty to refer (49.0%). The conditions most frequently felt to be appropriate for MAID included metastatic spine tumour (76.5%), malignant intramedullary tumour (64.7%), primary malignant spine tumour (54.9%), cervical spinal cord injury with tetraplegia (49.0%) and multiple myeloma (33.3%). Conclusions: This study highlights the complex landscape that exists when discussing MAID, but also the overall support of physicians, and need for ongoing conversations, particularly with issues not addressed by the current legislation.

Background: For robot-assisted telesurgery, the workstation, in particular the haptic handcontroller itself a robot, is paramount to the performance of surgery. Based on the requirements for microsurgery, a novel haptic handcontroller Excalibur has been developed. Methods: Thirty-two surgeons performed a peg-in-hole task (simulating micromanipulation) with Excalibur and two commercially available handcontrollers (Sigma 7 and PHANToM Premium 3.0). A modified Kuka endeffector with bipolar forceps, and Leica microscope completed the remote robotic site. Comparisons were made based on training time, task completion time and number of errors. All participants completed a questionnaire. Results: Repeated measures ANOVA demonstrated significance for task completion time (p=0.004), training time (p=0.021) and number of errors (p=0.004). Surgeons were faster with Excalibur (72s) than with Sigma (96s,p=0.005) and PHANToM (96s,p=0.036). Training time was shorter with Excalibur than with PHANToM (210s vs 310s,p=0.013), and users made fewer errors (0.7 vs 2.1,p=0.008). Training time required for Sigma (285s) and the number of errors (1.3) were not significant. The surgeons found Excalibur smoother, more comfortable, less tiring and easier to maneuver, with more realistic force feedback and superior movement fidelity. Conclusions: Surgical performance was superior with Excalibur compared to the other handcontrollers. This may reflect the microsurgical requirements and unique design architecture of Excalibur.

Background: The aim of this study is to assess factors impacting the postoperative length of stay (LOS) for patients undergoing microvascular decompression (MVD) surgery. Methods: A consecutive series of patients undergoing MVD at the Winnipeg Centre for Cranial Nerve Disorders were reviewed. All patients were monitored in a neurosurgical stepdown unit for at least 6 hours postoperatively and when medically stable discharged at their own discretion. The hospital LOS was measured in hours from midnight after day of surgery and categorized by days in hospital. Results: The 112 patients included 53 Manitobans (MB) and 59 from out of province (OOP). The overall LOS was 38±52 hours, and not significantly different between genders, diagnosis or age. LOS was significantly shorter for OOP versus MB patients (28±23/48±71 hours; p=0.02). OOP patients were also more often discharged on the first postoperative day (59% versus 32%; p=0.02) and 85% of them stayed at the hotel within the hospital complex prior to travelling home. Conclusions: Postoperative discharge to an adjacent hotel appears to have led to shorter LOS. These patients may have been reassured by the physical proximity to medical care. The utilization of discharge to an adjacent hotel or comparable faculty may reduce hospitalization days and associated costs.

Background: The aim of this study was to investigate intraoperative methods to generate patient-specific PMMA bone implants during a craniotomy. The proposed methods combine a cost-efficient, and non-invasive structured light scanner (SLS) as an imaging modality and a prototype printer for rapid generation of implant molds. Methods: This simulation study was performed using retrospective data from three craniotomy patients. The extracted bone flap and the cranial defect were scanned using a SLS, which generates a 3D surface model of an object by projecting a series of light-patterns on it. Prototype printed implant models were generated using two different techniques. The molds were then used to shape PMMA bone implants. These implants were evaluated regarding their accuracy to reconstruct the natural skull anatomy and compared to freehand formed implants. Results: The patient-specific bone implants reconstructed the preoperative anatomy with an average RMS error of 1.37mm (StDev 0.27), compared to an error of 1.5mm (StDev 0.43) for the freehand shaped implants. On average the intraoperative scanning time was 4.7min. The average time to generate and print the implant molds was 204 min. Conclusions: Results of this study have shown great promise for the proposed method to be used for patient-specific bone flap reconstruction during craniotomies.

Background: Idiopathic normal pressure hydrocephalus (iNPH) is a triad of impaired gait, cognition and urinary control in the setting of normal pressure ventriculomegaly. Various options for shunt implantation exist, but there is limited ability to predict outcome. Methods: This study is a retrospective chart review of 82 shunted patients for iNPH between 2007 and 2018. Factors examined included age, sex, lumbar puncture results, use of laparoscopic approach, type of shunt used, Charlson Comorbidity Index and imaging (callosal angle and DESH). Patient outcome was assessed via modified Rankin Scale (mRS). Results: 52 patients were male and 30 were female. Average age at surgery was 71.4 years. 58/62 (94%) improved following lumbar puncture. 41% of patients had VP shunt, and 59% of patients had LP shunt. 30/79 (38%) had laparoscopic placement of the distal catheter. 23/75 (31%) and 30/81 (36%) had a complication and required reoperation, respectively. Callosal angle showed statistically significant increase post-shunting (76 to 94 degrees, p<0.005). Presence of DESH did not change post-shunting. Average Charlson Comorbidity Index was 4.4. The mRS decreased from 3.84 to 2.66 post-operatively (p<0.005). Conclusions: In our centre, iNPH patients had clinicoradiologic improvement following shunting. We will perform regressional statistics to elucidate the factors influencing outcomes.

Background: Normal pressure hydrocephalus is a frequent cause of cognitive and functional impairment. Many symptoms are shared between Parkinson’s disease and normal pressure hydrocephalus. Only few studies examine extrapyramidal signs in NPH, and only one case report exists describing tremor improvement with shunting. Methods: We performed a retrospective chart review of our NPH database. We selected patients who had both NPH and question of Parkinsonism due to tremor. Results: Six patients with both NPH diagnosis and tremor were identified. Three patients were treated for Parkinson’s disease and followed by neurology. After shunting, all three improved and attempt was made to wean medications, which led to functional decline. The other three patients improved with shunting and after titration of the shunt had resolution of tremor. Conclusions: We provide evidence that NPH can result in tremor, treatable by shunting. We also emphasize that those patients do exist who have both diseases. This likely exists along a continuum. Careful consideration of NPH should be undertaken in those patients with suspected Parkinson’s disease and imaging findings reminiscent of NPH.

Background: Non-gunshot wound penetrating injury to the spinal canal have been known to have variable injury patterns with respect to trajectory and depth. Methods: We present a case of a penetrating glass fragment injury to the T11-12 level with a cerebrospinal fluid leak. Results: A T11-12 bilateral laminectomy and duraplasty with motor-evoked potential monitoring was performed to remove the foreign object and associated hematoma. The clinical presentation and surgical management are discussed with respect to other non-gunshot-related penetrating spine injuries in the literature. Conclusions: This case demonstrates a very rare injury pattern, as the vast majority of intradural penetrating injuries to the thoracic spine result in complete or incomplete spinal cord injury. This patient was neurologically intact, which is remarkable, given the 7cm glass fragment crossing the thoracic spinal canal transversely from the right to left.

Background: In spite of the shift towards “personalized medicine,” ambulatory medicine lags behind the cutting edge technology employed in non-medical fields to convey information in unique ways to enhance customer interactions. Furthermore, the complex nature of neurosurgical concepts can be difficult to convey within the confines of a short outpatient visit. These factors, coupled with potentially long wait times, can limit a patient’s engagement in the treatment process. We propose that application of advanced video platforms will empower patients to feel that neurosurgical concepts are accessible and understandable and enable the face-to-face time with the physician to begin at a more sophisticated level, ultimately improving patient engagment. Methods: 3D modeling, animation, and video game design were used in conjuction with tablet computers and VR headsets to create a video-driven “choose-your-own-adventure style patient experience” with initial use during waiting times prior to face-to-face interaction with the neurosurgery providers. Results: 3D modeling, animation, and virtual reality were successfully implemented in the Northwestern Medicine neurosurgery clinic with positive impact on patient engagement, including preliminary improvements in multiple patient satisfaction/”Likelihood to Recommend” scores. Conclusions: Advanced imaging platforms, including 3D modeling, animation, and virtual reality show great promise in improving patient engagement, patient retention, and “Likelihood to Recommend” scores.

Background: Postoperative C5 palsy (C5P) is a common complication after cervical decompression, potentially related to nerve root tethering. To our knowledge, this is the first study to investigate this hypothesis by comparing C5/C6 root translation and tension before and after root untethering by cutting cervical intraforaminal ligaments (IFL). Methods: Six cadaveric dissections were performed. Nerve roots were exposed and translation and tension measured after the roots and spinal-cord were dorsally displaced 5mm before and after IFL cutting. These were also measured during shoulder depression to simulate intraoperative positioning. Clinical feasibility of IFL release was examined by comparing standard and extended foraminotomies to compare resultant root translation. Results: IFL-cutting increased translation at both C5/C6 roots (P=0.001). There was no difference between root levels (P=0.33). IFL-cutting increased translation upon shoulder depression at both C5/C6 roots (P=0.003) with a difference also being found between root levels (P=0.02). An extended cervical foraminotomy was technically feasible which enabled complete IFL release and root untethering, whereas a standard foraminotomy did not. Conclusions: IFL-cutting increases root translation, suggesting they are either protective (preventing peripheral nerve strain from being transmitted to the spinal-cord) or harmful (by tethering intraforaminal nerve roots and potentially contributing to postoperative C5P) depending on the clinical context.

Background: Pedicle screw (PS) fixation is considered the gold-standard for spine stabilization. However, minimally invasive surgery (MIS) and cortical screw (CS) fixation have become commonplace. The biomechanical and safety profiles of CS compared to PS have yet to be determined. To our knowledge, this is the first study to describe a novel percutaneous CS approach and compare its safety and accuracy to PS fixation. Methods: Standard percutaneous PS fixation was performed using fluoroscopy from L1-L5 on one-side with percutaneous CS being placed on the other-side (10-instrumented PS and CS levels each). Anatomical confirmation and comparison of pedicle breach incidence was performed afterward via open dissection. Results: Dissection revealed no breaches of either construct. As such, no statistical comparison was possible. At one-level however, a CS was seen breaching the posterior-third lateral vertebral body under the superior end-plate. A couple of exposed screw threads were visualized well away from any entering and/or exiting foraminal or extra-spinal neurovascular structures. Conclusions: MIS and CS-based constructs are relatively new fixation techniques. We describe a novel percutaneous CS technique incorporating advantages of both MIS and CS-constructs. Although no difference was found in pedicle breach incidence, further study comparing these techniques and rigorous patient selection for application are necessary.

Background: The Saskatchewan Spine Pathway (SSP) facilitates timelier imaging and more appropriate surgical referrals. In this prospective study, pre- and post-operative wait times, satisfaction, and outcomes were compared between SSP and conventionally referred surgical patients. Methods: A prospective matched cohort comparison of 150 patients (SSP group n=75; conventional group n=75) undergoing elective lumbar surgery for mechanical back and leg pain between 2011 and 2016 was performed with 1 year follow-up. Outcomes were measured with patient questionnaires, Oswestry disability index (ODI), visual analogue back and leg pain scores (VAS), and EuroQol Group 5 –Dimension self-report (EQ5D). Results: Baseline measures were the same in both groups. Wait times to see the surgeon and for surgery were the same, and wait time for MRI was significantly shorter for the SSP group (p<0.001). SSP patients utilized more non-operative treatment strategies such as physiotherapy (p<0.04), and had higher satisfaction with pre-surgical care (p=0.03). Good surgical outcomes were obtained in both groups with no significant differences. Conclusions: There are minimal differences in post-surgical outcomes for SSP patients versus conventionally referred patients; however, the SSP facilitates significantly shorter wait times for MRI and non-operative treatment strategies. Pre-surgical patient satisfaction is significantly higher among SSP patients.

Background: The nerve root sedimentation sign (SedSign) has been correlated with clinically significant lumbar spinal stenosis (LSS), and promoted as a possible prognostic indicator. However, diagnostic methods were not clearly defined in prior reports. In this study, the clinically validated Saskatchewan Spine Pathway enabled diagnosis of neurogenic claudication due to LSS. The objective was to compare the outcome of lumbar laminectomy for neurogenic claudication with respect to SedSign. Methods: This was a retrospective analysis of prospectively-collected data in patients with neurogenic claudication who underwent lumbar laminectomy. Outcome measures included Oswestry Disability Index, Visual Analogue Scale (VAS) for back and leg pain, and EuroQol 5-Dimension questionnaire. Results: Laminectomy was performed in 106 patients, and 60 were SedSign positive. Outcomes did not differ with respect to SedSign for all outcome measures, in non-instrumented and instrumented cohorts. Improvement in walking distance was associated with dural cross-sectional area of stenosis (p=0.02). VAS back and leg improvements were associated with back dominant (p=0.038) and leg dominant (p=0.0036) pain. Conclusions: This is the largest analysis of SedSign with respect to operative outcomes, and the only study with validated criteria for defining neurogenic claudication. Although other radiological and clinical factors are associated with improvements, SedSign did not correlate with laminectomy outcome.

Background: Lumbar microdiskectomy is amongst the most common neurosurgical techniques. In Saskatoon, minimally invasive microdiskectomy using the MetrX tubular retractor system has become a routinely performed procedure. While the outcomes of microdiskectomy are known to be similar to open technique, long term outcomes have not been reported. Methods: We performed a retrospective study of 160 minimally invasive microdiskectomies. We excluded subjects with cauda equina syndrome, redo surgery, fusions, and multi-level decompressions. We used one-way ANOVA to compare VAS, ODI, SF36, and EQ5D scores at pre-operative, 6-week postoperative, and long-term timepoints. Results: The mean pre-operative back pain VAS score was 6.23+/−2.63, 6-week post-operative follow-up VAS was 3.21+/−2.49, and long-term follow-up VAS was 2.56+/−2.45. The mean preoperative leg pain VAS score was 7.66+/−1.99, 6-week follow-up VAS was 3.56+/−2.79, final follow-up VAS was 2.20+/−2.57. The mean preoperative ODI score was 60.41+/−13.97; falling to 32.54+/−20.57 at 6-week follow up, and further to 24.50+/−20.97 at long term follow up. The mean baseline EQ5D quality of life score was 46.4+/−18.1, 68.9+/−20.2 at 6-week follow up and 69.3+/−20.3 at final review. Data reached statistical significance. Conclusions: We report good outcomes for minimally invasive microdiskectomy that are as durable as published results using open technique.