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n I Introduction Intracranial neoplasms or brain most times routine, has become tumors compr ise on ly a sm a ll less and less frequent. In this percentage of the growths that day of micro tech nology a n d are seen in patients. Surgery to computers, surgeons are look- diagnose and treat brain tumors i ng to “bu i ld a bet ter mouse- can be quite involved for both trap.” Also, in an environment the patient as well as the per- of increased health care costs, sonnel involved in the operation lowered reimbursement for the itself. The traditional means of surgeons, and hospitals that are operating on intracranial neo- cracking down on lengthy sur- plasms was that of a craniot- gical procedures, stereotactic om y, which in volves r emoving navigational surgery has become and replacing a section of the an accepted modality in neuro- skull. This surgery, although at surgical practice.
JULY 2004 The Surgical Technologist 9
245 JULY 2004 2 CE CREDITS IN CATEGORY 1
Mi ni ma l ly i nvasive su rger y has become t he ionic contrast, computerized tomographic scan standard of care for the surgical patient. Wheth- of the head and frame. These images were then er it is a gallbladder that is being removed or the used to guide the biopsy needle into the area of resection of a colloid cyst of the third ventricle concern. The biopsy procedure itself was carried in the brain, the goals are the same: to provide out in the operating room using standard ster- the patient with a treatment of the disease or the ile technique. The skull was penetrated using a slowing of its symptoms, minimize the surgi- standard 7 mm burr hole. A biopsy needle was cal risk involved, preserve the normal anatomy, then introduced into the brain and a section of and most importantly, promote a rapid recov- tissue was removed. One tissue sample was rou- ery so the patient can return to work and family. tinely obtained. At the completion of the proce- The use of stereotactic navigation in the realm of dure, the patients were transferred to the recov- neurosurgery provides the patient and the sur- ery room, where they were closely monitored by geon a means of achieving these goals. the nursing staff. After a total of four hours of Several years ago, a patient being treated with observation, the surgeon assessed and approved cra niotomy for a tu mor was informed about the patient for discharge.1 the risks involved. These risks sometimes out- The most commonly diagnosed lesions were weighed the benefit of having the surgery. With that of glioblastoma multiforme (35 patients). the recent advances in stereotactic navigation, Other forms of brain cancer and infections com- the neurosurgeon is able to operate on the more prised the rest of the pathological f indings (41 refined areas of the brain with greater precision, patients). Bhardwaj and Bernstein also reported while reducing morbidity. the most common site of surgery was that of the frontal lobe.1 The success rate of the study was Review of literature 97.4% . Out of the 76 patients operated on, two Kelly stated that, “The stereotactic surger y of patients were not discharged from the hospital the future may employ all or a combination of because the biopsy procedure itself could not be t he following technologies: frameless stereo- performed, and the patients underwent extend- tac t ic su rger y, robot ic technolog y, microro- ed observation and further investigation.1 botic dexterity enhancement, and telepresence T he authors reported two compl ic at ions robotics.”7 This statement has never been more among the study group. One patient with a deep- true. A lt hough surger y is severa l years away seated glioma had degeneration of neurologi- from robots taking the place of skilled surgeons cal status. Another patient developed an intra- operating on fragile areas of the brain, there are ventricular hemorrhage as a complication of the other devices that are in the surgeon’s arsenal to procedure. Both of these patients were still dis- enhance the patient’s outcome from a potential- charged on the day of surgery.1 ly life-threatening surgery. The cost analysis was carried out using a soft- Bhardwaj and Bernstein surveyed the prac- ware program. The original figures are in Cana- tica lit y of per forming a bra in biopsy using a dian dollars, with US equivalents listed in paren- framed-based stereotaxis system from a finan- t heses.10 At t he institution where t he surger- cial and patient satisfaction standpoint.1 For a ies were performed, the cost of a one-night stay period of five years, from August 1996 to August in the intensive care unit is $2,400 CAD ($1,757 2001, the study was conducted on a total of 76 USD). The cost of a night’s stay in a neurosurgi- patients. The group was broken down into gen- cal step-down unit is $1,800 CAD ($1,318 USD). der, with 41 fema le and 35 ma le patients. The Fina l ly, t he cost of a home-care nurse v isit is mean age of the group was 56.9 years of age, with roughly $60 CAD ($44 USD). The current trend ages ranging from 18 to 86 years.1 A stereotac- for a brain biopsy is for a patient to spend one tic ring was secured to the patient’s head using night in the neurosurgical intensive care unit or local anesthetic. The patient underwent a non- step-down bed before being discharged. There-
10 The Surgical Technologist JULY 2004 Definitions of terms
Brain shift. A slight shift in brain position caused Pallidotomy: A surgical procedure in which a part by gravity acting on the brain after the skull is opened. of the brain, called the globus pallidus, is lesioned in The forces of gravity act upon the brain itself by pulling order to improve symptoms of tremor, rigidity, and bra- it toward the ground. This, combined with the aspira- dykinesia. A pallidotomy is a surgical procedure where a tion of cerebrospinal fluid, allows the brain to relax. needle is guided into the area of the brain that controls fine motor movement and a lesion is literally burned Collimation: The radiological method shaping into the patient’s brain, thus stopping the transmission and confining the X-ray beam to a given area based on of damaged signals to the extremities. the patient’s tumor. Radiosurgery: A technique for treating inopera- Ferromagnetic: Relating to or demonstrating ble brain cancers; a CT scan is used to locate the tumor, the magnetic attraction of iron containing materials. which is then bombarded with precise, high doses of radiation. Fiducials. Special stickers impregnated with bar- ium sulfate that create a radiopaque markers on the Sella turcica: The bony structure that houses the patient’s skull. These stickers take the place of a frame pituitary gland. being bolted to the patient’s head. Stereotactic: A radiation therapy technique Glioblastoma multiforme: A type of brain involving a rigid head frame that is attached to the skull; tumor that forms from glial (supportive) tissue of the high-dose radiation is administered through openings brain. It grows very quickly and has cells that look very in the head frame to the tumor while decreasing the different from normal cells. amount of radiation given to normal brain tissue.
Intracranial: Pertaining to inside the cranial vault. Transsphenoidal: Through the sphenoid bone. fore, the average savings of a strictly outpatient ed and covered with a sterile drape. Th e patient approach to stereotactic brain biopsies range was then transferred to the MRI scanner where from $, CAD ($, USD) to $, CAD the head was fixed in the scanner. Contrast ($, USD). enhanced images were then obtained. Although Bohinski et al reported on the use of magnet- total scan time of the patient varied, due to var- ic resonance imaging (MRI) to aid in the resec- ious imaging needs, the mean scanning time tion of glial cell brain tumors. The system uti- reported was that of minutes. If the area of lized in the study was that of a Hitachi vertical resection was satisfactory to the neurosurgeon’s field open MRI scanner. The scanner was locat- expectations, the skull was closed primarily in a ed adjacent to the operating suite. Although standard fashion in the MRI suite. However, if the cost of the scanner was not disclosed in the more resection was required, the patient could report, it can be said with confidence that a scan- then be brought back into the operating room. ner of this capacity costs in the area of $ to $. The accuracy of the MRI scans was quite million, with the building of a MRI-safe operat- impressive. Out of a total of patients, % of ing room and equipment adding $ to $ million the scans obtained were indistinct and unus- to the price tag. able. Materials in the room and on the patients Bohinski’s study stated that, after removal of themselves had interfered with the quality of the all visible tumor by the neurosurgeon, the dura magnetic images. These scan-altering objects mater, skull, and scalp were loosely approximat- were removed, and the patient was rescanned.
JULY 2004 The Surgical Technologist 11 In the study group, % of the patients required complication rate was reported at .% with sub- additional resection of the mass, and .% of the dural hematomas comprising .% of the report- patients in the group had worsening of neuro- ed complications. There were four deaths report- logical symptoms, with one patient who expired ed within the group comprising .% of the com- due to an unrelated air embolus in the pulmo- plications. Deaths only occurred in institutions nary artery. where the procedure is rarely performed. Th is is Even though the neurosurgical communi- due to superior intra- and postoperative care in ty has received great criticism for the use of the institutions that are familiar with the procedure, intraoperative MRI, Bohinski’s group argues the compared to that of an institution which per- importance of it. They state that, “one of the goals forms one to two of these surgeries a year. of our MROR (Magnetic Resonance Operating Cost analysis of the various procedures has Room) design was to incorporate suffi cient fl exi- been reviewed. The average length of stay of the bility so that other practitioners (those referring patients was reported at two days. Cost compar- patients for diagnostic imaging or those inter- ison was executed between the three types of ste- ested in developing peripheral interventions for reotactic surgery surveyed. Deep brain stimu- other organ systems) could use the MRI center lation (DBS) showed an increased cost because routinely.” the cost of the device that is implanted into the Although the primary use of the MRI was patient is quite expensive. The total cost for DBS for neurosurgical applications, other specialties was $,, compared to the lesion generating could subsequently utilize the scanner for their procedure at a mean cost of $,. own purposes. They also state the implementa- Hadani et al report on a new, innovative tion of guidelines for a less expensive route of intraoperative MRI scanner, built specifi cally for treating certain types of brain tumors before intracranial neuronavigation. This MRI scan- proceeding to employ the use of the MRI. ner, which conveniently fits under the operating Eskandar et al headed a long-term study of room table, thus eliminating the need for trans- , patients diagnosed with Parkinson’s dis- port of the patient to an MRI suite for imaging, is ease that were treated stereotactically from controlled by a neurosurgeon present in the ster- to . The surgical inter vention for ile fi eld. this study was performed at different hos- Although the MRI unit can be utilized in pitals by various neurosurgeons. Function- any existing operating room, some modifica- al neurosurgical treatment varied from patient tions must be undertaken to ensure the safety to patient. Sixty percent of the group studied and quality of the patient and images respective- received a stereotactic pallidotomy. A similar ly. Nonferromagnetic equipment, such as anes- procedure, a thalamotomy, was performed on thesia machines and microscopes, that must be % of the group. present in the room, are moved far enough from Deep brain stimulators, a pacemaker for the the magnet as to not to be drawn toward it. Stan- brain, were implanted in % of the study group. dard surgical instrumentation may be utilized. This newer, less invasive treatment has become However, MRI safe instrumentation is preferred the gold standard of care of patients with Par- because of the time and the traffi c involved with kinson’s disease. A reference frame was bolted moving the instruments to a safe location within to the patient’s skull, and the frame and the skull the room. Copper shielding was placed behind were then scanned together to aid the neurosur- the walls and ceiling of the operating suite to geon in placement of the electrodes deep in the eliminate any radio frequency interference from subcortical regions of the brain responsible for the rest of the surgical services department. motor movement. The navigational portion of this scanner is The mean age of the patients surveyed was rather simple. A sterile wand is supplied with years, with ages ranging from to years. Th e the system to locate the position of the resec-
12 The Surgical Technologist JULY 2004 tion margins in relation to the images acquired FIGURE throughout the surgical procedure in real time. These images are viewed on a liquid crystal dis- The play (LCD) monitor in three planes: axial, coro- nal, and sagittal. StealthStation® Of the patients included in the Hadani group study, of the surgeries were cranioto- guides the mies for tumor removal and six were transsphe- noidal approaches to the pituitary gland. For the surgeon through tumor removal group, the intraoperative MRI scan demonstrated the remaining tumor within the process of the brain. This enabled the surgeons to remove the entire residual tumor seen by the MRI scan. acquiring data for Concerning the pituitary surgery, Hadani uti-
lized the MRI navigation to aid the placement Medtronic, Inc by provided Image navigation. of the surgical speculum and instrumentation through the sphenoid and within the sella tur- cica. In addition, overall removal of the tumor cable system. was confirmed with the aid of the intraoperative T hese i mages MRI unit. are registered to the As with any new piece of equipment, there patient using a reference arc mounted close to is a learning curve associated with its use. Th is the skull. is especially true with this intraoperative MRI A study group was created from patients scanner. As the surgical team becomes more treated using this navigational system on pro- comfortable with the use of the equipment, the cedures and using standard fluoroscopy on the preparation and operative time is decreased. remaining patients. The average age of the Hadani’s study reported the average scan time patients in the group was . years. The types added to the operative time was from . to of tumors that were removed were, most com- minutes. No complications were reported with monly, pituitary adenomas and craniopharyngi- the use of the system. omas. The mean set-up time compared between Jane, Thapar, Alden, and Laws describe the the groups was not noteworthy. FluoroNav sur- use of a frameless stereotactic system to aid the geries were reported to be seven minutes longer surgeon into the sella turcica for a transsphenoi- than the standard fl uoroscopic procedure. Inter- dal resection of a pituitary gland tumor. Th e sys- estingly, the image-guided surgery times were tem used, the StealthStation® navigational sys- minutes faster than the traditional navigation. tem with FluoroNav™ virtual fl uoroscopy system The accuracy of the system was also reviewed. software, is manufactured by Medtronic Sofamor Not one single imaged guided surgery had to be Danek. The system utilizes fl uoroscopic images converted to a standard surgery. No complica- taken in the operating room to aid in navigation tions were reported. around the bony structures it has scanned. A The charges for billing were not significant relatively inexpensive system in comparison to between the two groups studied. The imag- others on the market, the system is easy to set up. ing guided platform added a cost of $ per The computer guides the surgeon systematical- patient in operative time. Another cost compar- ly through the process of acquiring and manip- ison was performed between the FluoroNav and ulating the images received to create data that is CT-guided frameless stereotaxy. Th e total cost useful to navigation. Utilizing the fl uoroscope, of utilizing FluoroNav was reported at $.. information is relayed to the computer via a The cost of using a frameless stereotactic system
JULY 2004 The Surgical Technologist 13 was determined to be $,.. Th is diff erence study group, five patients developed a compli- is due to the technical fee charged for using the cation. The most common complication was a computerized tomography scanner, the radiol- small hemorrhage formation at the site of biop- ogist fee, and the increased set-up time in the sy. Only one of the patients suff ered permanent operating room. neurological deficit. Deaths in three patients Kaakaji et al studied the potential conse- were reported, but they were not related to the quences of stereotactic brain biopsy patients who biopsy procedure itself. Out of the patients were discharged early from the hospital. Utiliz- who received the stereotactic brain biopsy, ing the ViewPoint frameless navigational sys- were well enough for same-day discharge. tem, patients were treated from January Economic analysis was directed toward hos- through July . The mean age of the patients pital charges, net revenue, direct costs, and was years. Each patient received a CT scan of indirect costs. Out of the patients surveyed, the brain to assess any problems that may have records were available for review. Revenue arisen aft er biopsy. After the scan was cleared, decreased % in short stay patients and % in the patients were then transferred to a nursing the extended observation patients. A direct cost to the hospital was seen to increase % and % for each group studied. Profits were reported to One of the goals of our MROR be % higher in the extended outpatient group (Magnetic Resonance Operating when compared to the short-stay group. Direct costs, however, were % higher. Room) design was to incorporate An abst ract f rom Pa leologos, Wad ley, sufficient flexibility so that other Kitchen, and Thomas on the use of image guid- practitioners (those referring ance during craniotomies for meningiomas patients for diagnostic imaging reviewed patients who had received sur- gery stereotactically and patients who had or those interested in developing received a traditional craniotomy. Although the peripheral interventions for other operative times associated with the two groups organ systems) could use the MRI were not significant, the image guided surgery group was shorter. Intensive care unit stay was center routinely. also compared. Image guided patients were in the intensive care unit for an average of one day, while the traditional craniotomy patient’s mean unit where they were observed for one day and length of stay was . days. Mean total hospi- then discharged. tal stay was reported at . days for the tradi- All the biopsy procedures were performed tional groups and . days for the image guid- utilizing CT or MRI guidance with the appli- ed group. cation of an external stereotactic frame or the Complications were lower in the image-guid- employment of a frameless system. Aft er admin- ed group when compared to the traditional sur- istration of general anesthesia, a standard mm gery group, % to % respectively. The most burr hole was created in the patient’s skull. Tis- common problem reported was that of hemato- sue specimens were obtained utilizing an aver- ma formation. The average cost increase of sur- age biopsy needle. Out of the group, % were gery per patient was % higher for the tradi- diagnosed with a tumor. The remaining diagno- tional surgery group than the image guided sur- ses included infection, stroke, and other neuro- gery group. logical disease processes. Cost analysis of stereotactic radiosurgery for Complications associated with this stereo- metastatic brain lesions versus an open approach tactic brain biopsy were compared. Out of the was surveyed by Rutigliano et al. The authors
14 The Surgical Technologist JULY 2004 reported that radiosurgery for metastatic brain while enhancing the standard of care and low- tumors showed a savings of $, when com- ering the costs in this period of reduced reim- pared to that of an open resection of the mass. A bursements. Several patients have received this lower complication cost per case was also appre- form of treatment, and it has proven itself near- ciated. This was studied by cost comparisons ly fl awless. This type of biopsy system has given from five sites that were used for radiosurgery. way to the next generation of stereotactic navi- gation. Discussion A frameless navigational system incorporates All the stereotactic systems reviewed have one the same principles, but involves a few other similarity: They all provide for a safer, less mor- components. The initial purchase of the sys- bid outcome than that of a standard “un-navi- tem consists of a computer platform, an infrared gated” intracranial surgery at a lower cost to the camera or magnetic field generator, and a refer- patient and facility. encing instrument. The computer is usually a Although the concepts are the same when high-speed platform that is capable of reproduc- choosing a stereotactic navigational system, the ing highly detailed images. The infrared camera purchase can be quite pricey. The least expensive basically is the eye of the system. In some sys- system is a framed system. This design consists tems, a magnetic field generator is used in place of a cylindrical ring that surrounds the patient’s of the infrared camera. Both variations encom- head and is held in place by literally screwing pass the same goal, which is to provide a probe bolts that are that attached to the frame into the recognized by the computer. patient’s skull. The frame is marked with specif- In frameless navigation, the brain of the ic coordinates measured in millimeters. Th ese patient is scanned in a computerized tomo- coordinates are used to help navigate the biopsy graphic scanner. Instead of a frame being bolt- needle or probe into the depths of the brain. Th e ed to the patient’s head, special stickers, called frame and the patient are then scanned togeth- “fiducials” are placed on the patient’s skin. Th ese er in a computerized tomographic scanner. Th e fiducials are impregnated with barium sul- images of the frame and patient are then used to fate to make them radiopaque. Th e fi ducials are give a trajectory to follow to allow the passage of arranged in such a way that they surround the instrumentation to its desired target. area to be operated. Surgeons place - fi ducials The concept of this type of navigation is not on the patient to increase the accuracy of the sys- new. The idea itself has been around since the tem. Once the patient has been scanned, he or late s when a framed stereotactic ring was she is taken to the operating room to be prepped used to study the brain in animal models. It was for surgery. The images obtained from the CT not until the early s that the idea had been scan are then loaded into the computer, and a brought up to use this new contraption in neuro- program is used to register or compare the fi du- surgery on human patients. cial makers on the screen with the ones that are Framed surgery is still utilized quite fre- on the patient. After the images and the patient quently today in this age of super comput- are registered with the computer, the surgeon ers and silicon technology. Surgery for Parkin- can proceed with the operation. Usually, a ster- son’s disease and other movement disorders are ile probe is used to identify the surgeon’s posi- being treated successfully using framed surgery. tion in relation to the images acquired earlier An increasing number of institutions are rec- that day. Some of the systems on the market pro- ognizing the importance of combining mini- vide instrumentation, such as suction tips and mal access surgery with stereotactic navigation. a clamp-on sensor, which allows the surgeon to The fact that a patient can have outpatient brain use any instrument to aid in the navigation. Th e surgery is no longer uncommon. It provides a accuracy of this system is high; room for error is means of increasing the patient satisfaction, between - mm.
JULY 2004 The Surgical Technologist 15 Frameless stereotactic navigation has become ger accurate. The brain can shift, on average, - the gold standard in the surgical treatment of mm. Th e shift may not seem large, but when a brain tumors. There are several factors to take neurosurgeon is operating on areas of the brain in account when an institution decides to under- that control motor movement and speech, every take a purchase of a navigational system. Obvi- micron counts. ously, the price is a major consideration. In the Neurosurgeons often prefer MRI naviga- middle price range, a frameless system off ers the tion to the other types when operating on brain surgeon an increased amount of fl exibility when tumors. Certain types of brain tumors, such as it comes to the surgical options. The system can glioblastoma multiforme, are only visible on an be utilized for a biopsy, navigation, or even pre- MRI scan and not to the naked eye. Th e finger- cise work, such as deep brain stimulator implan- like projections of this very aggressive and fatal tation for movement disorders, such as Parkin- type of primary brain cancer can only be detect- son’s disease and spastic rigidity. Most systems ed by MRI. on the market range from $, to $,. Brain shift, tumor visualization, and the This makes them affordable for the smaller, non- protection of vital areas of the brain show the teaching institutions. importance of an intraoperative MRI, but these Some systems may be used with other surgi- added benefits do not come without a profound cal disciplines in mind. Otorhinolaryngological cost. The average price of the MRI unit itself can surgeons are using the stereotactic navigation range from $- million, and does not include the technology to guide them into the intricate cav- cost of standard operating room equipment that ities of the paranasal sinus. Some of the systems is MRI compatible. This is not a purchase that on the market can be combined with other diag- most institutions encounter without some heavy nostic modalities such as fl uoroscopy. funding and several years of planning. Pituitary surgery, by tradition, has involved Various additional expenses and consider- the employment of ionizing radiation images ations add to the larger picture. One consider- to guide the surgeon through the nose, sinuses, ation involves how the unit will be housed. Some and eventually to the base of the brain where the institutions use the MRI in a standard operat- pituitary gland resides. This technique carried ing room that has been converted for MRI use. an extra risk for the personnel in the room. Now, Other hospitals use another dedicated room, the surgeon can take just a few snap-shots with outside the main operating room, to acquire the fluoroscopic unit, load them into the stereo- the data. The latter makes the MRI accessible tactic system, and use those images to guide the for diagnostic and other therapeutic procedures instruments into the brain, while eliminating when neurosurgery is not being performed. On the excessive exposure of X-rays to the person- the other hand, the risks of contaminating the nel and patients. All of this is possible without a wound and sterile field increase when the patient substantial increase in cost to the patient or the must be transported with a loosely closed skull hospital. and scalp and placed into the scanner. The latest and most expensive of all stereo- One manufacturer produces an MRI scanner tactic navigational systems is the intraopera- that fits neatly under the operating room table tive MRI. How can the expense of intraoperative and is raised and lowered as needed. This is espe- MRI for navigation within the brain be justifi ed? cially beneficial since minimal alteration to the Even though the two previously described sys- existing surgical suite is needed. During a scan, tems are very useful in brain biopsy and func- instrumentation and other ferromagnetic equip- tional neurosurgery, neither account for brain ment must be moved out of the magnetic fi eld, a shift. After the skull is opened and brain shift few feet from the scanner. This advance in tech- occurs, the images displayed on the computer nology has proven to be an eff ective adjunct to screen from a scan earlier in the day are no lon- the treatment of intracranial lesions.
16 The Surgical Technologist JULY 2004 The final type of stereotactic system is a this detail. The employment of a stereotactic radiosurgery system, or “knifeless” surgery sys- navigational system for intracranial surgery is a tem. This system utilizes radiation that has been piece of equipment that has become invaluable specifically shaped or collimated to the shape of in the operating room. the patient’s own tumor to destroy the tumor Traditionally, most neurosurgeons worked itself while preserving normal brain tissue. Th e off the CT scans obtained preoperatively and most popular type of system utilizes a robot- the anatomy of the brain he or she sees on the ic arm that moves about the patient’s head to operating room table. Although still very reli- approach the tumor from all angles. Although able, performing surgery this way carries an still in its infancy, radiosurgery has proven itself increased expense to the patient and the hospi- as the best choice of treatment for patients both tal, both economically and postoperatively. Ste- with intracranial lesions that are easily operable reotactic navigation provides the patient and the and those that are inoperable. It has also proven surgeon a means of receiving and performing a to be a cost savings device when compared to the minimally invasive surgery while enhancing the surgical systems surveyed. accuracy and ultimately the outcome of the sur- In recent years, stereotactic intracranial nav- igation has become an accepted addition to the neurosurgeon’s armamentarium. This has not The main goal of all come about without great controversy. Again, stereotactic navigation the price appears to be the primary factor. More institutions are being equipped with a guidance within the brain is to platform, because the accuracy of the system, a provide the surgical substantially lower complication rate, and the patient with a faster, more potential for a genuine outpatient surgery are accurate, safer surgery, realized when in comparison to a surgery with- out navigation. without morbidity or Several companies manufacture stereo- mortality, while decreasing tactic navigation systems on the market today. the overall cost to the Each system possesses unique features. Some are adaptable for spinal applications. Others can patient and the hospital. be used with or without a frame. The main goal of all stereotactic navigation within the brain is to provide the surgical patient with a fast- gery itself. Surgeries on once unreachable areas er, more accurate, safer surgery, without mor- of the brain are now possible by the use of a ste- bidity or mortality, while decreasing the overall reotactic system. Whichever system a hospital cost to the patient and the hospital. In the age chooses, it is not a purchase that should go with- of decreased reimbursement and managed care, out careful research of the surgeons’ needs. Also, this has never been more needed. it must be understood that the purchase of the system is not inexpensive, but the money saved Conclusion in postoperative care and increased standard of Every patient has the right to quality care when it patient care far outweigh the expense. comes to a surgical procedure. This includes the training of the surgeon, nurses, and other per- About the author sonnel directly involved with his or her treat- Jeffrey J Cortese, cst, has been a certified sur- ment. Most patients overlook the type of equip- gical technologist for since . A graduate of ment the surgeon will use to perform the proce- Baker College—Mt Clemens Campus, Cortese is dure. Hospital administrators also tend to miss imployed at St Joseph’s Mercy of Mancomb Hos-
JULY 2004 The Surgical Technologist 17 pital in Clinton Township, Michigan, and Wil- . Paleologos TS, Wadley JP, Kitchen ND, liam Beaumont Hospital in Troy, Michigan. He Thomas DGT. Clinical utility and cost-eff ec- is an adjunct instructor in the surgical technol- tiveness of interactive image-guided crani- ogy program and is working on a bachelor’s of otomy: Clinical comparison between con- health service administration at the Baker Col- ventional and image-guided meningioma lege in Clinton Township, Michigan. surgery. Neurosurgery. July ;():. Abstract from Neurosurgery Online. neu- References rosurgery-online.com/abstracts//NURO_ . Bhardwaj R D, and Bernstein M. Prospec- abstx.html Accessed // tive feasibility study of outpatient stereotac- . Rutigliano MJ, Lunsford LD, Kondziolka D, tic brain lesion biopsy. Neurosurgery. August Strauss MJ, Khanna V, Green M. The cost ;():-. effectiveness of stereotactic radiosurgery ver- . Bohinski RJ, Kokkino AK, Warnick RE, Gas- sus surgical resection in the treatment of sol- kill-Shipley MF, Kormos, DW, Lukin RR, Tew itary metastatic brain tumors. Neurosurgery. JM. Glioma resection in a shared-resource September ;():. Abstract from magnetic resonance operating room after Neurosurgery Online. neurosurgery-online.com/ optimal image-guided frameless stereotactic abstracts//NURO_abstx.html Accessed resection. Neurosurgery. ;():-. // . Eskandar EN, Flaherty A, Cosgrove GR, . Exchange rate figured // and rounded Shinobu LA, Barker II FG. Surgery for Par- to the nearest dollar. www.x-rates.com kinsonís disease in the United States, to : Practice patterns, short-term out- comes, and hospital charges in a nationwide sample. Journal of Neurosurgery. November ;:-. . Hadani M, Spiegelmam R, Feldman Z , Berkenstadt H, Ram Z. Novel, compact, intraoperative magnetic resonance imag- ing-guided system for conventional neu- rosurgical operating rooms. Neurosurgery. ;():-. . Jane Jr JA, Thapar K, Alden TD, Laws Jr ER. Fluoroscopic frameless stereotaxy for transsphenoidal surgery. Neurosurgery. ;():-. . Kaakaji W, Barnett GH, Bernhard D, War- bel A, Valaitis K, Stamp S. Clinical and eco- nomic consequences of early discharge of patients following supratentorial stereotactic brain biopsy. Journal of Neurosurgery. June ;:-. . Kelly PJ. Stereotactic surgery: What is past is prologue. Neurosurgery. ;():. Abstract from Neurosurgery Online. www. neurosurgery-online.com/abstracts// NURO_abstx.html Accessed //
18 The Surgical Technologist JULY 2004