British Journal of Neurosurgery, 2015; Early Online: 13

2015 The Neurosurgical Foundation

ISSN: 0268-8697 print / ISSN 1360-046X online
DOI: 10.3109/02688697.2015.1026799

TECHNICAL NOTE

3D printing of patient-specific anatomy: A tool to improve patient

consent and enhance imaging interpretation by trainees
YaorenLiew1, ErinBeveridge2, Andreas K.Demetriades3 & Mark A.Hughes3
1University of Edinburgh Medical School, Edinburgh, Midlothian, UK, 2School of Life Sciences, University of Glasgow,

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Glasgow, UK, and 3Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK

to render a 3D digital model of bone alone. This model was

segmented into a defined region of interest using free open
source Meshlab software (www.meshlab.sourceforge.net,
Institute of the National Research Council, Italy) and then
exported in standard tessellation language (STL) file format,
which is readable by 3D printers. CT images of a second
patient (case 2, a 64-year-old man with a T12 crush fracture) underwent similar post hoc processing. Both STL files
were uploaded to a Fortus 250 mc 3D printer (StratasysLtd,
Minneapolis, USA). A fused deposition modeling technique
(where the 3D model is printed layer by layer from the bottom
up) was used, printing the models in acrylonitrile butadiene
styrene (ABS). Image processing took between two and three
hours per model. Both models cost 150 (cost of ABS) and
took 48 h to fabricate, using readily available technology in
a university engineering department.

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

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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

can, once acquired, be transferred to other contexts or

other tissues. The technique used here offers the potential
to create hybrid constructs, allowing the fabrication of a
model combining, for instance, parts of the skull base, a
dural-based lesion, and nearby vessels.
Preoperatively prepared patient-specific 3D models can
be used to improve patient understanding and informed
consent. 3D printouts of bony neurosurgical pathology
also show promise as a tool to enhance trainees ability to
correlate 2D imaging with a tangible 3D reality. With the
current attention paid to sagittal balance, such tools can
also enhance 3D interpretation and surgical planning.
These compliment previously described uses in neurosurgical simulation environments,1 in addition to wellestablished patient-specific prostheses such as cranioplasty.
Experimental applications of 3D printing in the context of

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.

3D printing of patient-specific anatomy 3

tissue engineering and synthetic biology are also expanding.2 As 3D printing technology evolves, and costs fall,
patient-specific 3D printing may become routine for both
clinical and educational uses.

Declaration of interest: The authors report no declarations

of interest. The authors alone are responsible for the content
and writing of the paper.

References
Acknowledgements

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We thank Dr Zoe Morris for preparing anonymized CT

DICOM files, and Steve Gourlay at the University of Edinburgh School of Engineering for overseeing the 3D printing
process.

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multimaterial 3D printers in creating models with pathological
entities to enhance the training experience of neurosurgeons.
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2. Whatley BR, Kuo J, Shuai C, Damon BJ, Wen X. Fabrication of
a biomimetic elastic intervertebral disk scaffold using additive
manufacturing. Biofabrication 2011;3:015004.