Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
Book Review
Brief Report
Case Report
Case Series
Commentary
Editorial
Erratum
Guest Editorial
Images
Images in Neurology
Images in Neuroscience
Images in Neurosciences
Letter to Editor
Letter to the Editor
Letters to Editor
Letters to the Editor
Media and News
None
Notice of Retraction
Obituary
Original Article
Point of View
Position Paper
Review Article
Short Communication
Technical Note
Techniques in Neurosurgery
Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
Book Review
Brief Report
Case Report
Case Series
Commentary
Editorial
Erratum
Guest Editorial
Images
Images in Neurology
Images in Neuroscience
Images in Neurosciences
Letter to Editor
Letter to the Editor
Letters to Editor
Letters to the Editor
Media and News
None
Notice of Retraction
Obituary
Original Article
Point of View
Position Paper
Review Article
Short Communication
Technical Note
Techniques in Neurosurgery

Brief Report
14 (
1
); 156-160
doi:
10.25259/JNRP-2022-3-13

# Expanding access to microneurosurgery in low-resource settings: Feasibility of a low-cost exoscope in transforaminal lumbar interbody fusion

Department of Neurosurgery, Peoples’ Friendship University of Russia, Moscow, Russian Federation
Department of Neurosurgery, Dr. Alejandro Cabral Hospital, San Juan de la Maguana, Dominican Republic
Department of Spine Surgery, Central Clinical Hospital of the Russian Academy of Sciences, Moscow, Russian Federation
Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Charitéplatz, Berlin, Germany
Corresponding author: Ibrahim E. Efe, Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Charitéplatz, Berlin, Germany. ibrahim.efe@charite.de
Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Ramirez ME, Peralta I, Nurmukhametov R, Castillo RE, Castro JS, Volovich A, et al. Expanding access to microneurosurgery in low-resource settings: Feasibility of a low-cost exoscope in transforaminal lumbar interbody fusion. J Neurosci Rural Pract 2023;14:156-60.

## Objectives:

Less than a quarter of the world population has access to microneurosurgical care within a range of 2 h. We introduce a simplified exoscopic visualization system for low-resource settings.

## RESULTS

### Surgical outcome

There were no significant differences in mean operating duration and blood loss between the low-budget exoscope and the microscope groups [Table 3]. All patients reported satisfactory lumbar and radicular pain relief. No complications were encountered. In both groups, the postoperative course was uneventful, allowing early mobilization and discharge within 3 days after surgery.

### User experience

The questionnaire was anonymously filled by five neurosurgery residents, three senior neurosurgeons, and the chief of the department. Three users reported on their experience as first operators, whereas the remaining six reported on their experience as assistant operators. The overall user experience was positive [Figure 2]. Image quality, brightness, zoom, and focus functions were non-inferior to those of the operating microscope according to most users. Surgeon’s convenience and pre-operative set-up were rated largely similar. A striking advantage of the low-budget exoscope was reported to be its use in training. More than 60% of users absolutely agreed that it was superior to the microscope in teaching surgery. Further, anecdotal reports by the senior staff included that the lack of stereoscopic perception and the cumbersome adjustability of the camera may result in a shallow learning curve. Yet, close to 80% agreed that they would recommend the device to their colleagues and 70% wanted to continue using it in the future. The users unanimously agreed that the low-cost exoscope holds great potential for LMICs.

## DISCUSSION

We achieved similar outcomes with our low-cost exoscope as with the conventional operating microscope. These results were in line with the previous reports on exoscopes in neurosurgery.[8,9] The technology has gained popularity mainly due to enhanced surgeon’s comfort. The surgical field is projected to a screen allowing the surgeon to operate in a comfortable posture. The larger working distance results in more convenient instrument maneuverability and less obstruction when passing instruments in and out of the surgical field. The monitor allows the entire staff to follow the surgery from the first operator’s perspective instead of separate binocular objectives. The operator may become more aware of the rest of the operating room personnel, facilitating communication between all team members.[10,11] A recent survey showed that operating room staff felt more involved and could be of more help in exoscope-assisted surgeries than in those performed with a binocular microscope.[12] The small size of our device allowed full sterilization and easy transportation. Yet, our exoscope did not perform better than the microscope in terms of convenience. Adjusting the camera position was perceived to be cumbersome. Robotic exoscopes currently attempt to overcome this difficulty.[13] A support arm with greater freedom of motion might be a low-cost solution to achieve a more seamless workflow. According to our senior users, the lack of 3D vision was another major drawback. Our exoscope may not be suitable for deep and narrow surgical corridors, potentially limiting its use in cranial surgery. Existing exoscope systems already rely on 3D cameras to preserve image quality and depth perception while being ergonomically superior than the microscope. Novel technologies contain 4K-3D displays and fluorescent filters. The main limiting factor remains the high cost of such systems. The prices of currently available exoscopes range from $250.000 to$1.500.000.[13] While fluorescent filters help in complex microvascular and tumor surgeries, many neurosurgical operations in LMICs are still performed with no magnification due to the lack of equipment. We hope that our experiences with our \$150 low-cost exoscope may encourage neurosurgeons in LMICs to seek similar solutions to provide safe microneurosurgery.

### Limitations of the study

Our aim was to share our first experiences with the low-budget exoscope and to report operative data of our initial patient cohort. Hence, our sample size is small rendering statistical statements impossible. Further, we chose the TLIF procedure as it is a common spinal approach that many of our colleagues worldwide are familiar with. We cannot safely assume, however, that the low-budget exoscope would comply with the high standards of neuro-oncological or cerebrovascular operations. Thus, our results cannot be generalized to other surgical indications and careful consideration is mandatory when testing the device for other procedures or patient groups. Further, the questionnaire was filled by nine staff members of the Department of Spine Surgery at the Central Clinical Hospital of the Russian Academy of Sciences. Five were residents with limited microsurgical experience and four were senior specialists. Some could judge the feasibility from the main surgeon’s perspective, others only from that of the first assistant. Yet, all responses were pooled and quantified equally. Three of the nine survey respondents have co-authored this manuscript, rendering our survey prone to response bias. However, these three respondents joined the authors list only at the final stage of this study and were unaware that they would become coauthors at the time of exoscope use and survey participation.

## CONCLUSION

Our low-budget exoscope is safe and feasible for the use in TLIF. It is of significant benefit in surgical teaching. Yet, it is purchasable at a significantly lower price than conventional microscopes. We hope that this low-cost technology can help expand access to microneurosurgical care and training worldwide.

### Declaration of patient consent

Patient’s consent not required as there are no patients in this study.

### Conflicts of interest

There are no conflicts of interest.

Nil.

## References

1. . A new surgical procedure for lumbar disc herniation causing less tissue damage through a microsurgical approach In: , , , , , eds. Lumbar Disc Adult Hydrocephalus. Advances in Neurosurgery. Vol 4. Berlin, Heidelberg: Springer; . p. :74-80.
2. . Microsurgical operation of herniated lumbar disc In: , , , , , eds. Lumbar Disc Adult Hydrocephalus: Advances in Neurosurgery. Vol 4. Berlin, Heidelberg: Springer; . p. :81.
3. , , , , . The use of the exoscope in lateral skull base surgery: Advantages and limitations. Otol Neurotol. 2019;40:236-40.
4. . From Exoscope into the next generation. J Korean Neurosurg Soc. 2017;60:289-93.
5. , , , , , , et al. Neurosurgical care: Availability and access in low-income and middle-income countries. World Neurosurg. 2018;112:e240-54.
6. , , . Transforaminal lumbar interbody fusion (TLIF) JBJS Essent Surg Tech. 2016;6:e22.
7. , , . Minimally invasive lumbar fusion. 2003S26-35.
8. , . Three-dimensional, high-definition exoscopic anterior cervical discectomy and fusion: A valid alternative to microscope-assisted surgery. World Neurosurg. 2019;130:e244-50.
9. , , , , , . A high-definition 3D exoscope as an alternative to the operating microscope in spinal microsurgery. J Neurosurg Spine. 2020;33:705-14.
10. , , , , , . Clinical experience with a high definition exoscope system for surgery of pineal region lesions. J Clin Neurosci. 2014;21:1245-9.
11. , , , , , . Comparison of operating microscope and exoscope in a highly challenging experimental setting. World Neurosurg. 2021;147:e468-75.
12. , , , , , , et al. A practice survey to compare and identify the usefulness of neuroendoscope and exoscope in the current neurosurgery practice. Asian J Neurosurg. 2020;15:601.