The use of intraoperative neurosurgical ultrasound for surgical navigation in low- and middle-income countries: the initial experience in Tanzania

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>Neuronavigation has become a crucial tool in the surgical management of CNS pathology in higher-income countries, but has yet to be implemented in most low- and middle-income countries (LMICs) due to cost constraints. In these resource-limited settings, neurosurgeons typically rely on their understanding of neuroanatomy and preoperative imaging to help guide them through a particular operation, making surgery more challenging for the surgeon and a higher risk for the patient. Alternatives to assist the surgeon improve the safety and efficacy of neurosurgery are important for the expansion of subspecialty neurosurgery in LMICs. A low-cost and efficacious alternative may be the use of intraoperative neurosurgical ultrasound. The authors analyze the preliminary results of the introduction of intraoperative ultrasound in an LMIC setting.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>After a training program in intraoperative ultrasound including courses conducted in Dar es Salaam, Tanzania, and Aurora, Colorado, neurosurgeons at the Muhimbili Orthopaedic and Neurosurgical Institute began its independent use. The initial experience is reported from the first 24 prospective cases in which intraoperative ultrasound was used. When possible, ultrasound findings were recorded and compared with postoperative imaging findings in order to establish accuracy of intraoperative interpretation.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>Of 24 cases of intraoperative ultrasound that were reported, 29.2% were spine surgeries and 70.8% were cranial. The majority were tumor cases (95.8%). Lesions were identified through the dura mater in all 24 cases, with 20.8% requiring extension of craniotomy or laminectomy due to inadequate exposure. Postoperative imaging (typically CT) was only performed in 11 cases, but all 11 matched the findings on post–dural closure ultrasound.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>The use of intraoperative ultrasound, which is affordable and available locally, is changing neurosurgical care in Tanzania. Ultimately, expanding the use of intraoperative B-mode ultrasound in Tanzania and other LMICs may help improve neurosurgical care in these countries in an affordable manner.</jats:p></jats:sec>

Case report: Side-firing intraoperative ultrasound guided endoscopic endonasal resection of a clival chordoma

“…There are limitations to using IOUS in endoscopic endonasal surgery. Some neurosurgeons have little operating-room experience with ultrasound and must undergo IOUS training, which takes time and practice to develop confidence while interpreting US images intraoperatively (16,17). The US machine takes up space in the operating room and may require the repositioning of other equipment and changes to the workflow; however, the IOUS machine takes up far less space than iCT or iMRI machines.…”

Application of Intraoperative Ultrasound Navigation in Neurosurgery

“…Cost-effectiveness about acquisition, running, and maintenance of iUS apparatus – It is important to appreciate that the prohibitively high costs associated with CT- and MRI-based neuronavigation techniques limit their availability and use in LMICs ( 9 ).…”

“…Unfortunately, as is the case with any technique applied in many fields, iUS has some disadvantages, key of which is the steep learning curve. However, the investigators are of the opinion that the rate at which different surgeons will acquire the skill to effectively employ iUS is largely a function of their years of surgical experience ( 2 , 9 ).…”

Hemorrhage due to attempted excision of a frontal exophytic lesion: A cautionary tale

“…Recently in low-income and middle-income contexts, intraoperative ultrasound is shown to be a cost-effective and widely available tool for both diagnostic and neuronavigation/ surgical planning purposes, allowing multiple derivations of both intraoperative and preoperative usages. [ 4 ] In this context, the doppler ultrasonography might be a cost-effectively and widely available alternative in establishing differential diagnosis between a large subcutaneous lesion and an intracranial exophytic lesion demanding specialized neurosurgical care [ Figure 2 ]. [ 1 ]…”