Medical College of Wisconsin, School of Medicine, Milwaukee, Wisconsin, USA.
Department of Neurosurgery, Medical College of Wisconsin and Froedtert Hospital, Milwaukee, Wisconsin, USA.
World Neurosurg. 2023 Jul;175:e159-e166. doi: 10.1016/j.wneu.2023.03.045. Epub 2023 Mar 15.
Awake craniotomies are often performed with rigid pin fixation to support optical neuronavigation. Newer electromagnetic (EM) neuronavigation technology now enables unpinned cranial neurosurgery while maintaining robust intraoperative image guidance. Here, we share technical nuances, operative pearls, and lessons learned from our institutional experience using Curve EM neuronavigation during awake, unpinned craniotomies.
We describe our process for patient positioning, instrumentation setup, system registration, intraoperative navigation, and surgical adjunct use (e.g., intraoperative neuromonitoring and intraoperative magnetic resonance imaging) in detail. At each step, we provide pearls for success and tips for pitfall avoidance based on our experience.
Ten patients underwent awake pinless intra-axial tumor resection using Curve EM neuronavigation from May 2021 to August 2022 with a single surgeon. Postoperative transient neurological deficits were seen in 8 of 10 cases (80.0%), as all resections were taken to functional margins. Of the 9 patients with a 3-month follow-up visit at the time of publication, all 9 (100%) had improved or stable preoperative symptoms. No surgical complications, clinically appreciable inaccuracies, intraoperative losses of registration, unexpected postoperative magnetic resonance imaging findings, or errors related to the use of EM neuronavigation occurred.
The technical pearls outlined here will help interested neurosurgeons integrate EM neuronavigation into awake craniotomies. In our experience, using unpinned neuronavigation during awake cases provides many advantages to the patient, surgeon, and entire operative team. It has thus become the standard practice at our institution.
清醒开颅术常采用刚性钉固定以支持光学神经导航。新型电磁（EM）神经导航技术现在可以在不使用钉固定的情况下进行颅神经外科手术，同时保持强大的术中图像引导。在这里，我们分享了在使用 Curve EM 神经导航进行清醒、无钉开颅手术时从机构经验中获得的技术细节、手术技巧和经验教训。
我们详细描述了患者定位、仪器设置、系统注册、术中导航以及手术辅助设备（如术中神经监测和术中磁共振成像）的使用过程。在每个步骤中，我们根据经验提供了成功的要点和避免陷阱的技巧。
2021 年 5 月至 2022 年 8 月，一位外科医生使用 Curve EM 神经导航对 10 例患者进行了清醒无钉颅内肿瘤切除术。10 例患者中有 8 例（80.0%）术后出现短暂性神经功能缺损，因为所有的切除都达到了功能边缘。在发表时，有 9 例患者进行了 3 个月的随访，所有患者（100%）的术前症状均有改善或稳定。没有发生手术并发症、明显的临床不准确、术中注册丢失、意外的术后磁共振成像发现或与 EM 神经导航使用相关的错误。
这里概述的技术要点将帮助有兴趣的神经外科医生将 EM 神经导航整合到清醒开颅术中。根据我们的经验，在清醒病例中使用无钉神经导航可为患者、外科医生和整个手术团队带来许多优势。因此，它已成为我们机构的标准做法。
