V.E. Olyushin, A.Yu. Ylitin, K.S. Burnin, D.A. Gulyaev, L.N. Maslova
Polenov Research Neurosurgical Institute Saint Petersburg, Russia
The III Congress of Russian Neurosurgeons was held in Saint Petersburg on June 4-8, 2002. One of the problems, discussed at the Congress, was quick and safe removal of neoplasms of the brain and spinal cord. Peculiar attention was paid to performing more radical interventions with the best possible functional result. At the same time special emphasis was laid on necessity of providing due technical support of such operations and supplying neurosurgical clinics and regional neurosurgical centers of Russia with operating microscopes of optimum design, high-quality microsurgical instruments, navigation systems, up-to-date ultrasonic destructors and the newest resuscitative equipment.
According to statistics, the rate of cerebral tumors is 10-15 cases per 100 000 men/year. There is a tendency of its continuous and considerable growth. Surgical care is rendered to 20 000-30 000 patients with this disease annually. Unfortunately, lack of modern equipment in some neurosurgical clinics does not allow to perform radical operations in many of them. First of all, it concerns cases with solid tumors, located in difficult-of-access intracranial areas and characterized by complex interrelations with major vessels, cranial nerves and stem structures. Radical removal of such neoplasms with minimum damage of adjacent cerebral tissues is impossible without a powerful ultrasonic destructor.
CUSA 200 and Cusa Exel destructors are used successfully in some Russian clinics, including the Polenov Research Neurosurgical Institute (Saint Petersburg). Today these apparatus are the most potential and convenient means, giving a chance to make operations, which were considered to be impracticable earlier. In contrast to other instruments (aspirators, electric cutting loops, bipolar forceps, lasers), ultrasonic aspirators make it possible to remove a tumor much quicker, causing no damage to major vessels. Use of cavitation energy does not result in tissue carbonization and deep spread of warmth within it; new destructors of 36 kHz with curved high-precision microtips provide a good picture of an operative field during application of an operating microscope.
The first CUSA NS 100 device (1978) was a new standard of surgical equipment. The CUSA Exel apparatus, used today, possesses a broad spectrum of adjustment potentialities and is very effective both in vast resection of neoplasms and microsurgical interventions. Thanks to its technical parameters, the CUSA Exel system is the most powerful means of destruction among analogous devices; besides, it possesses the highest tissue selectivity. For example, the main technical method in meningiomas is ultrasonic preparation of a tumor node. Big neoplastic vessels are clipped temporarily and small vessels are subject to coagulation. Devascularization of tumor areas ensures subsequent resection of its fragments with the help of usual scissors. Besides, a unique combination of ultrasonic energy with an electrosurgical effect permits to remove neoplasms with considerable vascularization. When resection of glial tumors is performed, they are separated from adjacent tissues; hemostasis is achieved by coagulaton of small vessels. A great advantage of this system lies in a possibility to choose the optimum cavitation mode without reducing tissue selectivity.
Here are some clinical examples.
Female patient T., aged 40, with sphenopetroclival meningioma on the left side and involvement of the ICA supraclinoid segment, MCA and cavernous sinus. Neoplasm dimensions are 7x6 cm. Radical removal without damage of vessels became possible only due to the ultrasonic aspirator (Fig.1).
Female patient M., aged 47, with astocytoma of medulla oblongata of extra-intramedullary localization, spreading up to the second cervical vertebra. Total resection with application of the CUSA Exel aspirator resulted in complete regress of neurologic symptoms (marked tetraparesis and bulbar disorders) (Video).
Female patient A., aged 45, with giant meningioma of falx-tentorial angle on the right side; the tumor was characterized by extreme density, vast matrix and marked vascularization. The CUSA Excel aspirator made it possible to perform radical resection with minimum blood loss (Fig.2).
Thus, availability of the CUSA Exel system and its use in clinical practice allow to solve many problems, arising in surgical interventions on the brain and spinal cord. Today it is possible to resect tumors, whose removal was considered to be unattainable earlier, and even neoplasms of extreme density. Variety of tips ensures removal of a tumor of any localization.
Of course, in order to provide neurosurgical establishments with such devices, one will have to face a problem of money, as a value of all modern technologies is very high.
Nevertheless, it should be stated, that supply of clinics with up-to-date equipment is a necessary condition for performing adequate interventions. And, thus, its value is measured in such units, as health and life of patients.