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TECHNICAL NOTE
Br J Neurosurg
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Glasgow, UK, and 3Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK
Abstract
We report the use of three-dimensional or 3D printed, patientspecific anatomy as a tool to improve informed patient consent
and patient understanding in a case of posterior lumbar
fixation. Next, we discuss its utility as an educational tool to
enhance imaging interpretation by neurosurgery trainees.
Keywords: 3D printing; medical education; patient consent
Background
Three-dimensional (3D) printing is a form of rapid prototypingan additive manufacturing process, where objects
are built by a machine that lays down successive layers of a
thermoplastic material. 3D printers make it feasible to fabricate tangible anatomical and pathological structures from
computed tomography (CT) and magnetic resonance (MR)
images. As the printing hardware becomes more available
and more affordable, opportunities for use in clinical and
educational contexts abound.
Discussion
In case 1, the model was used as an adjunct to the preoperative consent process. She responded positively, saying
that the bespoke model helped her to better understand the
nature of her disease and the purpose and process of the surgical procedure. Its use during explanation gave her a much
better idea of what was to happen during surgery, which
reassured her, and consequently she reported feeling more
involved with decisions regarding her care. Seeing a physical
copy of her spine did not make her feel uncomfortable. She
attributed a maximum positive value of 5 on a Likert scale
for overall satisfaction with information given regarding the
procedure. It would be interesting to see whether these positive responses impact upon actual outcomes after surgery.
This would require a much larger series (or even randomized
trial), together with formal assessment of validated outcome
measures.
Clinical details
The anonymized lumbosacral CT images of a 54-year-old
female planned for elective L4L5 posterior lumbar fixation
for spondylolisthesis (case 1) were imported into a free open
source medical imaging manipulation platform (www.slicer.
org, Massachusetts, USA). A thresholding tool allowed discrimination of bone from soft tissue by manually defining a
selected density range. Segmentation of bone is straightforward and was performed accurately and without recourse
for neuroradiological input. Segmentation of soft tissues is
feasible but would require greater expertise and more time.
Asubsequent algorithm interpolated all individual 2D images
Correspondence: Mark Antony Hughes MB ChB BSc (Hons), Department of Clinical Neurosciences, Western General Hospital, Crewe Road South,
Edinburgh, EH4 2XU, UK. Email: mhughes4@staffmail.ed.ac.uk
Received for publication 1 November 2014; accepted 2 March 2015
Br J Neurosurg
Downloaded from informahealthcare.com by Kainan University on 04/02/15. For personal use only.
2 Y. Liew et al.
In case 2 (Fig. 1), the model was assessed for its utility as an educational tool. Twelve neurosurgical trainees
at a Scottish regional training session (ranging from ST1
to ST8) were presented first with the raw CT data (scrollable in axial, sagittal, and coronal planes) and then the
3D model, which they were encouraged to handle and
manipulate. 11 of 12 trainees reported that the 3D printout improved their spatial understanding of the patients
anatomy beyond that achieved when viewing CT images
alone. 5 of 12 trainees thought that such models could
enhance their ability to both assess the pathology and to
formulate management plans. 12 of 12 trainees thought
that such models could enhance teaching. Bony anatomy
is arguably easier to conceptualize in three dimensions
than soft tissues. It would be interesting to assess whether
this capacity to translate from two to three dimensions
Fig. 1. Illustration of the image processing and fabrication process for case 2, a T12 crush fracture. (A) Raw imported CT images; (B) after application
of thresholding according to density; (C) digital 3D model of bony structures; (D) the segmented region of interest; and (EG) ventral, lateral, and
dorsal views of the final printed model, respectively.
References
Acknowledgements
Br J Neurosurg
Downloaded from informahealthcare.com by Kainan University on 04/02/15. For personal use only.