The top-cited military relevant spine articles

Introduction

Historically musculoskeletal injury has substantially affected United States (US) service members. Lumbosacral spine injuries are among the most common sites of injury for service members across all US military branches and usually presents with pain in the lower back and extremities. The aim of this study is to identify and describe the 50 most-cited articles relevant to military medicine on the subject of the spine.

Methods

In April 2020 Web of Science was used to search the key words: spinal cord injury, spine, thoracic spine, lumbar spine, cervical spine, sacrum, sacral, cervical fusion, lumbar fusion, sacral fracture, combat, back pain, neck pain, and military. Articles published from 1900 to 2020 were evaluated for relevance to military spine orthopaedics and ranked based on citation number. The 50 most-cited articles were characterized based on country of origin, journal of publication, affiliated institution, topic, military branch, and conflict.

Results

1900 articles met search criteria. The 50 most-cited articles were cited 24 to 119 times and published between 1993 and 2017. 30 articles (60%) originated in the United States. Aviation, Space, and Environmental Medicine accounted for the most frequent (n = 10) destination journal followed by Spine (n = 8). 37 institutions contributed to the top 50 most-cited articles. The most common article type was clinically focused retrospective analysis 36% (n = 18), clinically focused cohort study 10% (n = 5), and clinically focused cohort questionnaire, cross-sectional analysis, and randomized study 8% each (n = 4). 90% of articles were non-surgical (n = 45). The US Army had the greatest number of associated articles. Operation Iraqi Freedom and Operation Enduring Freedom were the most-cited conflicts.

Conclusion

The 50 most-cited articles relevant to military spine orthopaedics are predominantly clinically focused, arising from the US, and published in Aviation, Space, and Environmental Medicine, Spine, and The Spine Journal.

Recent Outcomes and Challenges of Artificial Intelligence, Machine Learning, and Deep Learning in Neurosurgery

Neurosurgeons receive extensive technical training, which equips them with the knowledge and skills to specialise in various fields and manage the massive amounts of information and decision-making required throughout the various stages of neurosurgery, including preoperative, intraoperative, and postoperative care and recovery. Over the past few years, artificial intelligence (AI) has become more useful in neurosurgery. AI has the potential to improve patient outcomes by augmenting the capabilities of neurosurgeons and ultimately improving diagnostic and prognostic outcomes as well as decision-making during surgical procedures. By incorporating AI into both interventional and non-interventional therapies, neurosurgeons may provide the best care for their patients. AI, machine learning (ML), and deep learning (DL) have made significant progress in the field of neurosurgery. These cutting-edge methods have enhanced patient outcomes, reduced complications, and improved surgical planning.

Post-pandemic paradigm shift toward telemedicine and tele-education; an updated survey of the impact of Covid-19 pandemic on neurosurgery residents in United States

Background

Several strategies were implemented during the Covid-19 pandemic to enhance residency training and patient care.

Objective

This study aims to assess the post-pandemic landscape of neurosurgical training and practice.

Method

A survey consisting of 28 questions examining the challenges faced in neurosurgery and the adaptive measures was conducted among US neurosurgery residents from May 2022 to May 2023.

Results

This study encompassed 59 neurosurgical residents, predominantly male (72.9%) and in later years of training (66.1%) and were distributed across 25 states. Telemedicine and tele-education were pivotal during the pandemic, with virtual lecture series, standalone lectures, and virtual discussions highly favored. Remote didactic learning increased for nearly half of the residents, while 54.2% resumed in-person instruction. Telemedicine was deemed effective by 86.4% for evaluating neurosurgical patients. Access to teaching environments was restricted for 61.0% of residents, impacting their training. The pandemic significantly influenced elective surgeries, with complete cancellations reported by 42.4%. Reduced faculty engagement was noted by 35.6% of residents, while 47.5% reported a negative impact on the overall resident experience. The majority (76.3%) considered changes to their training reasonable given the global health situation.

Conclusions

Strategies implemented during the peak of the pandemic remain crucial in shaping neurosurgery training. Telemedicine has become indispensable, with widespread adoption. Tele-education has also expanded, providing additional learning opportunities. However, traditional didactic courses and hands-on experiences remain essential for comprehensive training. Balancing technology-driven methods with established approaches is crucial for optimizing neurosurgical education and maintaining high-quality patient care.

Atypical presentation of a posterior fossa tumour: A case report

BACKGROUND

We described a case of a patient with a meningioma in the posterior fossa presenting atypically with an isolated unilateral vocal cord palsy causing severe respiratory distress. This is of interest as the patient had no other symptomatology, especially given the size of the mass, which would typically cause a pressure effect leading to neurological and auditory symptoms.

CASE SUMMARY

This case report described a 48-year-old male who was married with two children and employed as a car guard. He had a medical history of asthma for the past 10 years controlled with an as-needed beta 2 agonist metered dose inhaler. He initially presented to our facility with severe respiratory distress. He reported a 1-wk history of shortness of breath and wheezing that was not relieved by his bronchodilator. He had no constitutional symptoms or impairment of hearing. On clinical examination, the patient’s chest was “silent.” Our initial assessment was status asthmaticus with type 2 respiratory failure, based on the history of asthma, a “silent chest,” and the arterial blood gas results.

CONCLUSION

A posterior fossa meningioma of such a large size and with extensive infiltration rarely presents with an isolated unilateral vocal cord palsy. The patient’s chief presenting feature was severe respiratory distress, which combined with his background medical history of asthma, was misleading. Clinicians should thus consider meningioma as a differential diagnosis for a unilateral vocal cord palsy even without audiology involvement.

Natural history of Chiari I malformation with syrinx and dilatation of the central canal in the pediatric population: the CHEO experience

PURPOSE

Given that syrinx is often considered an indication of surgery in children with Chiari I malformation (CM1), understanding of the natural history of these patients is very challenging. In this study, we investigate the natural history of children with CM1 that have syrinx and/or prominence of the central canal on presentation.

METHODS

All pediatric Chiari I patients who had syrinx and/or prominence of the central canal who underwent MR imaging of the head and spine from 2007 to 2020 were reviewed. Patients were divided into 3 groups (early surgery, delayed surgery, and conservative management). We focused on those patients who did not initially undergo surgery and had at least 1 year of clinical follow-up. We assessed if there were any radiological features that would correlate with need for delayed surgical intervention.

RESULTS

Thirty-seven patients met the inclusion criteria. Twenty-one patients were female and 16 were male. The mean age at presentation was 8.7 (5.8 SD). Fourteen (38%) patients had early surgical intervention, with a mean of 2.5 months after initial presentation, 8 (16%) had delayed surgery due to new or progressive neurological symptoms and 46% of patients did not require intervention during follow-up. The length of tonsillar herniation and the position of the obex were associated with the need of surgery in patients who were initially treated conservatively.

CONCLUSION

In pediatric patients with CM1 with syringomyelia and prominence of the central canal, conservative treatment is initially appropriate when symptoms are absent or mild. Close follow-up of patients with CM1 and dilatation of the central canal who have an obex position below the foramen magnum and greater tonsillar herniation is suggested, as these patients show a trend towards clinical deterioration over time and may require earlier surgical intervention.

Internal jugular vein fistula mimicking dural arteriovenous fistula after cardiac pacemaker placement

Carotid jugular arteriovenous fistulas are a documented complication of cannulation of the internal jugular vein. They may present with neck pain, headache, and cardiovascular aberrations. However, carotid jugular fistula secondary thrombus formation after jugular cannulation with radiographic presentation similar to dural arteriovenous fistula has not yet been reported in the literature. Below, we report the case of a 68-year-old male with an incidentally found carotid-jugular fistula secondary to pacemaker placement who had intracranial reflux on imaging, which was ultimately treated successfully through an endovascular approach.

Effect of remimazolam vs propofol on emergence from general anesthesia in patients undergoing cerebral endovascular procedures: A randomized controlled, non-inferiority trial

STUDY OBJECTIVE

This study aimed to compare the time to emergence from general anesthesia with remimazolam versus propofol in patients undergoing cerebral endovascular procedures.

DESIGN

A prospective, double-blind, randomized controlled, non-inferiority trial.

SETTING

An academic hospital.

PATIENTS

Adult patients scheduled for cerebral endovascular procedures.

INTERVENTIONS

Patients were randomized at a 1:1 ratio to undergo surgery under general anesthesia with remimazolam (0.1 mg kg-1 for induction and 0.3-0.7 mg kg-1 h-1 for maintenance) or propofol (1-1.5 mg kg-1 for induction and 4-10 mg kg-1 h-1 for maintenance).

MEASUREMENTS

The primary outcome was the time to emergence from anesthesia. The non-inferiority margin was -2.55 min in group difference. Major secondary outcomes included hypotension during induction, incidence of postoperative delirium and Modified Rankin Scale (mRs) at 30 days and 90 days after surgery.

MAIN RESULTS

Of the 142 randomized patients, 129 completed the trial. In the modified intention-to-treat analysis, the mean time to emergence from anesthesia was 16.1 [10.4] min in the remimazolam group vs. 19.0 [11.2] min in the propofol group. The group difference was -2.9 min [95% CI -6.5, 0.7] (P = 0.003 for non-inferiority). The remimazolam group had lower rate of hypotension during induction (11.3% vs 25.4%, P = 0.03) and use of vasopressors during surgery (29.6% vs 62.0%, P < 0.001). The two groups did not differ in postoperative delirium and mRs at 30 and 90 days after surgery.

CONCLUSIONS

In patients undergoing cerebral endovascular procedures, remimazolam did not increase the time from anesthesia vs propofol.

Impaired creative cognition after surgery for an IDH-mutated glioma: A proof-of-concept study

Assessment of high cognitive functions, such as creativity, is often overlooked in medical practice. However, it is crucial to understand the impact of brain tumors, specifically low-grade gliomas, on creative cognition, as these tumors predominantly affect brain regions associated with cognitive creativity. In this study, we investigated creative cognition using the Alternative Uses Task (AUT) and the Combination of Associates Task (CAT) in a cohort of 29 patients who underwent brain surgery for a low-grade glioma, along with 27 control participants. While the group of patients did not exhibit deficits in clinical neuropsychological assessments, our results revealed significant impairment in generating original and creative ideas compared to the control group. Furthermore, when analyzing the specific brain regions affected by the tumors, patients with lesions overlapping the left rostro-lateral prefrontal cortex, a critical region for creativity, displayed more pronounced impairments in the CAT compared to patients with lesions outside this region. These findings provide proof of concept that patients can experience impaired creative cognition following surgery for low-grade glioma, highlighting the importance of assessing higher-order cognitive functions, including creativity, in neurosurgical patients. Moreover, beyond its clinical relevance, our study contributes to advancing our understanding of the neuroscience of creativity.

Aspirin interruption before neurosurgical interventions: A controversial problem

Aspirin is widely used for primary or secondary prevention of ischemic events. At the same time, chronic aspirin consumption can affect blood clot formation during surgical intervention and increase intraoperative blood loss. This is especially important for high-risk surgery, including neurosurgery. Current European Society of Cardiology guidelines recommend aspirin interruption for at least 7 d before neurosurgical intervention, but this suggestion is not supported by clinical evidence. This narrative review presents evidence that challenges the necessity for aspirin interruption in neurosurgical patients, describes options for aspirin effect monitoring and the clinical implication of these methods, and summarizes current clinical data on bleeding risk associated with chronic aspirin therapy in neurosurgical patients, including brain tumor surgery, cerebrovascular procedures, and spinal surgery.

Extended reality in cranial and spinal neurosurgery - a bibliometric analysis

PURPOSE

This bibliometric analysis of the top 100 cited articles on extended reality (XR) in neurosurgery aimed to reveal trends in this research field. Gender differences in authorship and global distribution of the most-cited articles were also addressed.

METHODS

A Web of Science electronic database search was conducted. The top 100 most-cited articles related to the scope of this review were retrieved and analyzed for trends in publications, journal characteristics, authorship, global distribution, study design, and focus areas. After a brief description of the top 100 publications, a comparative analysis between spinal and cranial publications was performed.

RESULTS

From 2005, there was a significant increase in spinal neurosurgery publications with a focus on pedicle screw placement. Most articles were original research studies, with an emphasis on augmented reality (AR). In cranial neurosurgery, there was no notable increase in publications. There was an increase in studies assessing both AR and virtual reality (VR) research, with a notable emphasis on VR compared to AR. Education, surgical skills assessment, and surgical planning were more common themes in cranial studies compared to spinal studies. Female authorship was notably low in both groups, with no significant increase over time. The USA and Canada contributed most of the publications in the research field.

CONCLUSIONS

Research regarding the use of XR in neurosurgery increased significantly from 2005. Cranial research focused on VR and resident education while spinal research focused on AR and neuronavigation. Female authorship was underrepresented. North America provides most of the high-impact research in this area.

A light in the darkness: sodium fluorescein-assisted peripheral nerve sheath tumors resection - a comprehensive systematic review and single-arm meta-analysis

The treatment for peripheral nerve sheath tumors (PNSTs) is based on surgical excision and the primary goal is to improve symptoms whilst preserving neurological function. In order to improve this technique, surgeons may use sodium fluorescein (SF) to help visualize the neoplasm and, consequently, facilitate its removal. Aiming to assess the efficacy of this emerging surgical strategy, we conducted a systematic review and single-arm meta-analysis. We conducted a systematic search on the PubMed, Embase, and Web of Science databases, following the PRISMA guidelines. Studies without outcomes of interest, case series with less than four patients, letters, comments, technical notes, editorials, reviews, and basic research papers were excluded. The outcomes considered for this study were: the number of tumors that achieved total resection, subtotal resection, or near total resection, the approach/technique utilized by the surgeon, SF-related complications, and total complications. Five studies, with a total of 175 individuals, were included in our survey. Notably, 70% of the neoplasms presented by the patients were schwannomas. Considering extracranial lesions, we found a proportion of 96% (95% CI: 88 - 100%) in total resection, 0% (95% CI: 0-1%) in near total resection, and 4% (95% CI: 0-12%) in subtotal resection, all linked to an amount of 185 analyzed PNSTs. Furthermore, a proportion of 1% (95% CI: 0 - 2%) in SF-related complications was spotted among 183 patients. Finally, total complications analysis accounted for 11% (95% CI: 0 - 25%) among 183 individuals. We concluded that SF-assisted resection of PNSTs is a suitable and relatively safe technique, linked to minimum complications, of which the majority was not associated with the chemical compound itself. Future research is necessary to increase the number of patients available in the current literature and, therefore, enhance future analyses.

Green Hospital as A New Standard in Japan: How far can Neurosurgery go in Japan?

BACKGROUND

Climate change is a significant challenge that the medical community must address. Hospitals are large facilities with high water and energy consumption, as well as high levels of waste generation, which makes it important to pursue green hospital initiatives. Neurosurgery requires substantial energy for surgeries and tests.

METHODS

Based on the keywords "Climate change," "green hospital," "neurosurgery," "energy consumption," "environmental impact" listed in this paper, we extracted representative manuscripts, and the practices employed in the authors' hospital were assessed.

RESULTS

The "Guidelines for Environmental Consideration in Hospitals" and "Guidelines for the Sustainability of Hospital Environments" have been developed; however, they are not implemented in most hospitals in Japan. Inhalational anaesthetics were found to contribute significantly to greenhouse gas emissions. Educating patients and staff and employing the "8 Rs" (rethink, refuse, reduce, reuse, recycle, research, renovation and revolution) showed promise in achieving green hospital standards.

CONCLUSION

The advent of 'green hospitals' in Japan is imminent. The active participation of neurosurgeons can play a crucial role in diminishing the environmental footprint of health care while simultaneously enhancing medical standards. Given the pressing challenges posed by climate change, there is a critical need for an overhaul of medical practices. It is imperative for neurosurgeons to pioneer the adoption of new, sustainable medical methodologies.

Beware of epistaxis: fatal pseudoaneurysm rupture 30 years after treatment of acromegaly

We present a fatal complication of treatment in a patient with early-onset acromegaly, treated with two transsphenoidal operations, radiotherapy, radiosurgery and pegvisomant. He was diagnosed in his 30s, and controlled from his 40s, with stable residual tumour within the left cavernous sinus. In his 60s, 30 years after surgery/radiotherapy and 14 years after radiosurgery, he developed recurrent episodes of mild epistaxis. A week later, he presented at his local hospital's emergency department with severe epistaxis and altered consciousness. He was diagnosed with a ruptured internal carotid artery (ICA) pseudoaneurysm, but unfortunately died before treatment could be attempted.ICA pseudoaneurysms are rare complications of surgery or radiotherapy and can present with several years of delay, often with epistaxis. This case highlights the importance of life-long monitoring in patients with previous pituitary interventions and early recognition of epistaxis as a herald sign of a potentially catastrophic event, thus leading to timely treatment.

Post-trial access to implantable neural devices: an exploratory international survey

Objectives

Clinical trials of innovative neural implants are rapidly increasing and diversifying, but little is known about participants' post-trial access to the device and ongoing clinical care. This exploratory study examines common practices in the planning and coordination of post-trial access to neurosurgical devices. We also explore the perspectives of trial investigators on the barriers to post-trial access and ongoing care, as well as ethical questions related to the responsibilities of key stakeholder groups.

Design setting and participants

Trial investigators (n=66) completed a survey on post-trial access in the most recent investigational trial of a surgically implanted neural device they had conducted. Survey respondents predominantly specialized in neurosurgery, neurology and psychiatry, with a mean of 14.8 years of experience working with implantable neural devices.

Main outcome measures

Outcomes of interest included rates of device explantation during or at the conclusion of the trial (pre-follow-up) and whether plans for post-trial access were described in the study protocol. Outcomes also included investigators' greatest 'barrier' and 'facilitator' to providing research participants with post-trial access to functional implants and perspectives on current arrangements for the sharing of post-trial responsibilities among key stakeholders.

Results

Trial investigators reported either 'all' (64%) or 'most' (33%) trial participants had remained implanted after the end of the trial, with 'infection' and 'non-response' the most common reasons for explantation. When asked to describe the main barriers to facilitating post-trial access, investigators described limited funding, scarcity of expertise and specialist clinical infrastructure and difficulties maintaining stakeholder relationships. Notwithstanding these barriers, investigators overwhelmingly (95%) agreed there is an ethical obligation to provide post-trial access when participants individually benefit during the trial.

Conclusions

On occasions when devices were explanted during or at the end of the trial, this was done out of concern for the safety and well-being of participants. Further research into common practices in the post-trial phase is needed and essential to ethical and pragmatic discussions regarding stakeholder responsibilities.

Toward a Frontierless Collaboration in Neurosurgery: A Systematic Review of Remote Augmented and Virtual Reality Technologies

INTRODUCTION

Augmented Reality (AR) and Virtual Reality (VR) technologies have been introduced to Neurosurgery with the goal of improving the experience of human visualization. In recent years, the application of remote AR and VR has opened new horizons for neurosurgical collaboration across diverse domains of education and patient treatment. Herein, we aimed to systematically review the literature about the feasibility of this technology and discuss the technical aspects, current limitations, and future perspectives.

METHODS

Following the PRISMA guidelines, four databases (PubMed, Embase, Scopus, and Cochrane Library) were queried for articles discussing the use of remote AR and VR technologies in Neurosurgery. Data were collected in various fields, including surgery type, application type, subspecialty, software and hardware descriptions, haptic device utilization, visualization technology, internet connection, remote site descriptions, technical outcomes, and limitations. Data were summarized as counts and proportions and analyzed using IBM® SPSS® software.

RESULTS

Our search strategy generated 466 records, out of which 9 studies satisfied the inclusion criteria. The majority of AR and VR applications were used in cranial procedures (77.8%), mainly in education (63.6%), followed by telesurgical assistance (18.2%), patient monitoring (9.1%), and surgical planning (9.1%). Local collaborations were established in 55.6% of the studies, while national and international partnerships were formed in 44.4% of the studies. AR was the main visualization technology, and 3G internet connection was predominantly used (27.5%). All studies subjectively reported the utility of remote AR and VR for real-time interaction. The major technical challenges and limitations included audiovisual latency, the requirement for higher-fidelity and resolution image reconstructions, and the level of proficiency of the patient with the software.

CONCLUSION

The results from this systematic review suggest that AR and VR technologies are dynamically advancing to offer remote collaboration in Neurosurgery. Although still incipient in development and with an imperative need for technical improvement, remote AR and VR hold a frontierless potential for patient monitoring, neurosurgical education, and long-distance surgical assistance.

Ki-67 index as a predictive marker of meningioma recurrence following surgical resection

BACKGROUND

Meningiomas are the most common primary intracranial tumors in adults. Although benign in a majority of cases, they have a variable clinical course and may recur even after a thorough surgical resection. Ki-67, a nuclear protein involved in cell cycle regulation, has been widely studied as a marker of cellular proliferation in various cancers. However, the prognostic significance of Ki-67 in meningiomas remains controversial. Here, we investigate the Ki-67 index, as a predictive marker of meningioma recurrence following surgical resection and compare it to established prognostic markers such as WHO grade and degree of resection.

METHODS

The medical records of 451 patients with previously untreated cranial meningiomas who underwent resections from January 2011 to January 2021 at North Shore University Hospital (NSUH) were reviewed. Collected data included WHO grade, Ki-67 proliferative index, degree of resection - gross (GTR) vs subtotal (STR) - as judged by the surgeon, tumor location, and meningioma recurrence. This study was approved by the NSUH Institutional Review Board IRB 21-1107.

RESULTS

There were 290 patients with grade I, 154 with grade II, and 7 with grade III meningiomas. The average post-resection follow-up period was 4 years, and 82 tumors (18 %) recurred. Higher WHO grades were associated with higher rates of recurrence, with rates of 11.4 %, 27.9 %, and 71.4 % for grades 1, 2, and 3, respectively, and subtotal resection corresponded to a higher rate of recurrence than total resection (34.3 % and 13.4 %, respectively). Higher WHO grades also correlated with higher Ki-67 scores (2.59, 10.01, and 20.71) for grades 1, 2, and 3, respectively. A multivariate logistic regression model identified Ki-67 and degree of resection as independent predictive variables for meningioma recurrence, with Ki-67 specifically predicting recurrence in the WHO grade II subset when analyzed separately for WHO grades I and II.

CONCLUSION

Our 10-year retrospective study suggests that the Ki-67 index is an important predictive marker for recurrence of intracranial meningiomas following surgical resection, particularly among patients with WHO grade II tumors. Our findings add to a growing body of data that support inclusion of Ki-67 index in the WHO grading criteria for patients with meningiomas.

Appearance of intracranial cottonoids on intraoperative magnetic resonance imaging

To our knowledge, this is a unique report of intraoperative magnetic resonance imaging (iMRI) of an intracranial cottonoid. The current literature describes images of cottonoids as a post-operative finding in the setting of an unintentionally retained foreign body; however, the iMRI images we present are important as the use of iMRI in the resection of complex tumors and epilepsy foci increases. This series of images was obtained during a craniotomy for tumor resection of a patient with dysembryoplastic neuroepithelial tumor. To determine both the degree of tumor resection and the amount of residual tumor, cottonoids were left in our patient's resection cavity and underwent iMRI. The ability to distinguish cottonoids in these images is important for intraoperative localization of resection margins and to prevent the retention of cottonoids.

Hyperspectral and multispectral imaging in neurosurgery: a systematic literature review and meta-analysis

INTRODUCTION

The neuro-surgical community is witnessing a rising interest for surgical application of multispectral/hyperspectral imaging. Several potential technical applications of this optical imaging are reported, but the set-up is variable and so are the processing methods. We present a systematic review of the relevant literature on the topic.

MATERIALS AND METHODS

A literature search based on the PRISMA principles was performed on PubMed, SCOPUS, and Web of Science, using MESH terms and Boolean operators. Papers regarding intra-operative in-vivo application of multispectral and/or hyperspectral imaging in humans during neurosurgical procedures were included. Papers reporting technologies related to radiological applications were excluded. A meta-analysis on the performance metrics was also conducted.

RESULTS

Our search string retrieved 20 papers. The main applications of optical imaging during neurosurgery concern tumour detection and improvement of the extent of resection (15 papers) or visualization of perfusion changes during neuro-oncology or neuro-vascular surgery (5 papers). All the retrieved articles were pilot studies, proof of concepts, or case reports, with limited number of patients recruited. Sensitivity, specificity, and accuracy were promising in most of the reports, but the metanalysis showed heterogeneous approaches and results among studies.

CONCLUSIONS

The present review shows that several approaches are currently being tested to integrate hyperspectral imaging in neurosurgery, but most of the studies reported a limited pool of patients, with different approaches to data collection and analysis. Further studies on larger cohorts of patients are therefore desirable to fully explore the potential of this imaging technique.

Successful adaptation of twinning concept for global neurosurgery collaborations-a validation study

INTRODUCTION

Globally, many regions have an urgent, unmet need of neurosurgical care. A multi-step neurosurgical twinning technique, International Neurosurgical Twinning Modeled for Africa (INTIMA), was proved to be successful during a previous mission to Neurosurgical Unit, Enugu, Nigeria. The Swedish African Neurosurgical Collaboration (SANC) performed a developmental mission together with the local neurosurgical unit in The Gambia, adopting the INTIMA model.

METHODS

A multidisciplinary team visited for a 2-week collaborative mission at the Neurosurgical Department of the Edward Francis Small Teaching Hospital in Banjul, The Gambia. The mission followed the data of neurosurgical operations during and after the mission as well as about the operations 3 months prior to and after the mission was collected.

RESULTS

During the mission, a total of 22 operations was carried out, the most common being degenerative spinal conditions (n = 9). In the 3 months following the mission, 43 operations were performed compared to 24 during the 3 months leading up to the mission. The complexity of the performed procedures increased after the mission. An operating microscope (Möller-Wedel) was donated and installed and the neurosurgeons on site underwent training in microneurosurgery. The surgical nurses, nurses at the postoperative ward, and the physiotherapists underwent training. A biomedical engineer serviced multiple appliances and devices improving the patient care on site while training local technicians.

CONCLUSION

This study validated the use of the INTIMA model previously described in a mission by Swedish African Neurosurgical Collaboration (SANC). The model is sustainable and produces notable results. The core strength of the model is in the multidisciplinary team securing all the aspects and steps of the neurosurgical care. Installation of an operating microscope opened for further microsurgical possibilities, improving the neurosurgical care in The Gambia.

Staged neurosurgical approach for giant and progressive neonatal arachnoid cysts: a case series and review of the literature

OBJECTIVES

Prenatally diagnosed complex arachnoid cysts are very rare. While the true prenatal incidence is still unknown, they account for approximately 1% of intracranial masses in newborns. They rarely exhibit rapid growth or cause obstructive hydrocephalus, but if they increase to such a dimension during pregnancy, the ideal management is not well established. We present our detailed perinatal experience, covering prenatal diagnosis, a compassionate delivery process, and neonatal stabilization. Finally, a thorough postnatal neurosurgical intervention was performed. Initially, our focus was on the gradual reduction of cyst size as a primary effort, followed by subsequent definitive surgical treatment.

METHODS

This case series shows the treatment course of three fetuses with antenatally diagnosed large arachnoid cysts. We present pre- and postnatal management and imaging, as well as the surgical treatment plan and the available clinical course during follow-up.

RESULTS

Two girls and one boy were included in the current review. All three cases presented with prenatally diagnosed complex arachnoid cysts that increased in size during pregnancy. The mean gestational age at delivery was 35 weeks (range 32 to 37 weeks), and all patients were delivered by a caesarian section. Increasing head circumference and compression of brain structures were indications for delivery, as they are associated with a high risk of excess intracranial pressures and CSF diapedesis, as well as traumatic delivery and maternal complications. All cysts were supratentorial in location; one expanded into the posterior fossa, and one was a multicompartment cyst. All children underwent an initial surgical procedure within the first days of life. To relieve cyst pressure and achieve a reduction in head circumference, an ultrasound-guided or endoscopic-assisted internal shunt with drainage of the cyst to the ventricles or subdural/subarachnoid space was inserted. Definite surgical therapy consisted of cyst marsupialization and/or cysto-peritoneal shunt implantation. All children survived without severe neurodevelopmental impairments.

CONCLUSION

With the cases presented, we demonstrate that the slow reduction of immense cyst size as an initial procedure until optimal requirements for final surgical treatment were achieved has proven to be optimal for neurological outcome. Special emphasis has to be taken on the delicate nature of premature newborn babies, and surgical steps have to be thoroughly considered within the interdisciplinary team.

Letter to editor: Scalp incision technique for decompressive hemicraniectomy: Comparative systematic review and meta‑analysis of the reverse question mark versus alternative retroauricular and Kempe incision techniques of published cases

The "Letter to the Editor" titled "Scalp incision technique for decompressive hemicraniectomy: comparative systematic review and meta-analysis of the reverse question mark versus alternative retroauricular and Kempe incision techniques of published cases" provides a detailed analysis of different scalp incision techniques in decompressive hemicraniectomy procedures. While commendable for its systematic approach and valuable insights, the letter has several limitations, including a lack of transparency in the search strategy, failure to address potential sources of bias, and a narrow focus on technical aspects without considering broader outcome domains and practical considerations. Despite these limitations, the letter underscores the importance of evidence-based decision-making in neurosurgical practice and calls for further research to address these gaps.

Ethical Considerations of Neuralink and Brain-Computer Interfaces

Neuralink is a neurotechnology company founded by Elon Musk in 2016, which has been quietly developing revolutionary technology allowing for ultra-high precision bidirectional communication between external devices and the brain. In this paper, we explore the multifaceted ethical considerations surrounding neural interfaces, analyzing potential societal impacts, risks, and call for a need for responsible innovation. Despite the technological, medical, medicolegal, and ethical challenges ahead, neural interface technology remains extremely promising and has the potential to create a new era of medicine.

A realistic aneurysm clipping simulation combining 3D-printed and placenta-based models-how I do it

INTRODUCTION

Neurovascular surgery, particularly aneurysm clipping, is a critical skill for aspiring neurosurgeons. However, hands-on training opportunities are limited, especially with the growing popularity of endovascular techniques. To address this challenge, we present a novel neurovascular surgical training station that combines synthetic 3D-printed models with placental vascular structures to create a semi-realistic surgical field.

METHODS

Our model consists of three components: a 3D-printed skull replica with anatomical landmarks, a malleable silicone parenchyma with a Sylvian fissure, and vascular layers (placenta). The placental vascular layer is catheterized and perfused to replicate pulsatile flow, offering a realistic aneurysm simulation. This innovative training station provides a cost-effective solution (approximately 200 USD once) without ethical constraints. Surgeons can practice essential skills such as Sylvian fissure dissection, managing anatomical constraints like bone, and achieving proximal vascular control. The model's realism allows for training in various scenarios, including clipping with different hand orientations and handling ruptures realistically.

CONCLUSION

Our neurovascular surgical station bridges the gap between existing training models, offering affordability, ecological considerations, and minimal ethical concerns. It empowers neurosurgery residents to refine their skills in handling both emergencies and elective cases under close-to-real surgical conditions, with the potential for independent practice and senior supervision.

Neurosurgery compared to orthopedic spine consultation: A single level I trauma center experience

Introduction

Both Orthopedic Surgery (OS) and Neurosurgery (NS) perform spine surgery in the setting of trauma. However, it is unknown whether outcomes differ between these specialties. This study compares management and outcomes for vertebral fractures between NS and OS, hypothesizing similar operation rate, length of stay (LOS), and readmission.

Research question

Do outcomes differ between NS and OS in the management of vertebral fractures following trauma?

Methods

A retrospective single-center study was conducted on adult patients with cervical, thoracic, lumbar, and sacral fractures treated at a single trauma center, where no standardized pathway exists across NS and OS. Patients were compared for injury profile, diagnostic imaging, and operative techniques as well as LOS, mortality, and complications.

Results

A total of 630 vertebral fracture patients (OS:350 (55.6%); NS:280 (44.4%)) were included. NS utilized magnetic resonance imaging (MRI) more commonly (36.4% vs. 22.6%, p < 0.001). NS patients more often underwent operation (13.2% vs. 7.4%, p = 0.016) despite similar fracture number and severity (p > 0.05). Post-operative complications, LOS, and readmission rates were similar between cohorts (p > 0.05).

Discussion and conclusion

Despite similar injury profiles, NS had higher rates of MRI usage and operative interventions in the context of traumatic spine fractures. Despite differences in management, major clinical outcomes were similar between NS and OS. However, we do call for further standardization of evaluation and treatment of patients based on established algorithms from such as the AOSpine Thoracolumbar Spine Injury Classification System (ATLICS).

Perioperative Neurocognitive Function in Glioma Surgery

PURPOSE OF REVIEW

This review provides a concise overview of the recent literature regarding preoperative and postoperative neurocognitive functioning (NCF) in patients with glioma. Brief discussion also covers contemporary intraoperative brain mapping work, with a focus on potential influence of mapping upon NCF outcomes following awake surgery.

RECENT FINDINGS

Most patients with glioma exhibit preoperative NCF impairment, with severity varying by germ line and tumoral genetics, tumor grade, and lesion location, among other characteristics. Literature regarding postoperative NCF changes is mixed, though numerous studies indicate a majority of patients exhibit immediate and short-term worsening. This is often followed by recovery over several months; however, a substantial portion of patients harbor persisting declines. Decline appears related to surgically-induced structural and functional brain alterations, both local and distal to the tumor and resection cavity. Importantly, NCF decline may be mitigated to some extent by intraoperative brain mapping, including mapping of both language-mediated and nonverbal functions. Research regarding perioperative NCF in patients with glioma has flourished over recent years. While this has increased our understanding of contributors to NCF and risk of decline associated with surgical intervention, more work is needed to better preserve NCF throughout the disease course.

Venous thromboembolism chemical prophylaxis after skull base surgery

PURPOSE

There is no guidance surrounding postoperative venous thromboembolism (VTE) prophylaxis using pharmacological agents (chemoprophylaxis) in patients undergoing skull base surgery. The aim of this study was to compare VTE and intracranial haematoma rates after skull base surgery in patients treated with/without chemoprophylaxis.

METHODS

Review of prospective quaternary centre database including adults undergoing first-time skull base surgery (2009-2020). VTE was defined as deep vein thrombosis (DVT) and pulmonary embolism (PE) within 6 months of surgery. Multivariate logistic regression was used to determine factors predictive of postoperative intracranial haematoma/VTE. Propensity score matching (PSM) was used in group comparisons.

RESULTS

One thousand five hundred fifty-one patients were included with a median age of 52 years (range 16-89 years) and female predominance (62%). Postoperative chemoprophylaxis was used in 81% of patients at a median of 1 day postoperatively. There were 12 VTE events (1.2%), and the use of chemoprophylaxis did not negate the risk of VTE entirely (p > 0.99) and was highest on/after postoperative day 6 (9/12 VTE events). There were 18 intracranial haematomas (0.8%), and after PSM, chemoprophylaxis did not significantly increase the risk of an intracranial haematoma (p > 0.99). Patients administered chemoprophylaxis from postoperative days 1 and 2 had similar rates of intracranial haematomas (p = 0.60) and VTE (p = 0.60), affirmed in PSM.

CONCLUSION

Postoperative chemoprophylaxis represents a relatively safe strategy in patients undergoing skull base surgery. We advocate a personalised approach to chemoprophylaxis and recommend it on postoperative days 1 or 2 when indicated.

A Narrative Review on 3D Visualization Techniques in Neurosurgical Education, Simulation and Planning

INTRODUCTION

High-fidelity visualization of anatomical organs is crucial for neurosurgical education, simulation, and planning. This becomes much more important for minimally invasive neurosurgical procedures. Realistic anatomical visualization can allow resident surgeons to learn visual cues and orient themselves with the complex 3D anatomy. Achieving full fidelity in 3D medical visualization is an active area of research, however, the prior reviews focus on the application area and lack the underlying technical principles. Accordingly, the present study attempts to bridge this gap by providing a narrative review of the techniques used for 3D visualization.

MATERIALS AND METHODS

We conducted a literature review on 3D medical visualization technology from 2018 to 2023 using the PubMed and Google Scholar search engines. The cross-referenced manuscripts were extensively studied to find literature that discusses technology relevant to 3D medical visualization. We also compiled and ran software applications that were accessible to us in order to better understand them.

RESULTS

We present the underlying fundamental technology used in 3D medical visualization in the context of neurosurgical education, simulation, and planning. Further, we discuss and categorize a few important applications based on the 3D visualization techniques they use.

CONCLUSIONS

The visualization of virtual human organs has not yet achieved a level of realism close to reality. This gap is largely due to the interdisciplinary nature of this research, population diversity, and validation complexities. With the advancements in computational resources and automation of 3D visualization pipelines, next-gen applications may offer enhanced medical 3D visualization fidelity.

Evaluation of the safety, accuracy, and helpfulness of the GPT-4.0 Large Language Model in neurosurgery

BACKGROUND

Although prior work demonstrated the surprising accuracy of Large Language Models (LLMs) on neurosurgery board-style questions, their use in day-to-day clinical situations warrants further investigation. This study assessed GPT-4.0's responses to common clinical questions across various subspecialties of neurosurgery.

METHODS

A panel of attending neurosurgeons formulated 35 general neurosurgical questions spanning neuro-oncology, spine, vascular, functional, pediatrics, and trauma. All questions were input into GPT-4.0 with a prespecified, standard prompt. Responses were evaluated by two attending neurosurgeons, each on a standardized scale for accuracy, safety, and helpfulness. Citations were indexed and evaluated against identifiable database references.

RESULTS

GPT-4.0 responses were consistent with current medical guidelines and accounted for recent advances in the field 92.8 % and 78.6 % of the time respectively. Neurosurgeons reported GPT-4.0 responses providing unrealistic information or potentially risky information 14.3 % and 7.1 % of the time respectively. Assessed on 5-point scales, responses suggested that GPT-4.0 was clinically useful (4.0 ± 0.6), relevant (4.7 ± 0.3), and coherent (4.9 ± 0.2). The depth of clinical responses varied (3.7 ± 0.6), and "red flag" symptoms were missed 7.1 % of the time. Moreover, GPT-4.0 cited 86 references (2.46 citations per answer), of which only 50 % were deemed valid, and 77.1 % of responses contained at least one inappropriate citation.

CONCLUSION

Current general LLM technology can offer generally accurate, safe, and helpful neurosurgical information, but may not fully evaluate medical literature or recent field advances. Citation generation and usage remains unreliable. As this technology becomes more ubiquitous, clinicians will need to exercise caution when dealing with it in practice.

Multidisciplinary Consensus on Curricular Priorities for Pediatric Neurocritical Care Nursing Education: A Modified Delphi Study in the United States

BACKGROUND

Nurses are vital partners in the development of pediatric neurocritical care (PNCC) programs. Nursing expertise is acknowledged to be an integral component of high-quality specialty patient care in the field, but little guidance exists regarding educational requirements to build that expertise. We sought to obtain expert consensus from nursing professionals and physicians on curricular priorities for specialized PNCC nursing education in pediatric centers across the United States.

METHODS

We used a modified Delphi study technique surveying a multidisciplinary expert panel of nursing professionals and physicians. Online surveys were distributed to 44 panelists over three rounds to achieve consensus on curricular topics deemed essential for PNCC nursing education. During each round, panelists were asked to rate topics as essential or not essential, as well as given opportunities to provide feedback and suggest changes. Feedback was shared anonymously to the panelist group throughout the process.

RESULTS

From 70 initial individual topics, the consensus process yielded 19 refined topics that were confirmed to be essential for a PNCC nursing curriculum by the expert panel. Discrepancies existed regarding how universally to recommend topics of advanced neuromonitoring, such as brain tissue oxygenation; specialized neurological assessments, such as the serial neurological assessment in pediatrics or National Institutes of Health Stroke Scale; and some disease-based populations. Panelists remarked that not all centers see specific diseases, and not all centers currently employ advanced neuromonitoring technologies and skills.

CONCLUSIONS

We report 19 widely accepted curricular priorities that can serve as a standard educational base for PNCC nursing. Developing education for nurses in PNCC will complement PNCC programs with targeted nursing expertise that extends comprehensive specialty care to the bedside. Further work is necessary to effectively execute educational certification programs, implement nursing standards in the field, and evaluate the impact of nursing expertise on patient care and outcomes.

A cross-sectional survey of patient perceptions of the National Neurosurgical Audit Programme (NNAP)

BACKGROUND

The National Neurosurgical Audit Programme (NNAP) publishes mortality outcomes of consultants and neurosurgical units across the United Kingdom. It is unclear how useful outcomes data is for patients and whether it influences their decision-making process. Our aim was to identify patients' perceptions and understanding of the NNAP data and its influences.

MATERIALS AND METHODS

This single-centre study was conducted in the outpatient neurosurgery clinics at a regional neurosurgical centre. All adult (age ≥ 18) neurosurgical patients, with capacity, were invited to take part. Native and non-native English speakers were eligible. Statistical analyses were performed on SPSS v28 (IBM). Ethical approval was obtained.

RESULTS

A total of 84 responses were received (54.7% females). Over half (51.0%) of respondents felt that they understood a consultant's mortality outcomes. Educational level determines respondents' understanding (χ2(8) = 16.870; p = .031). Most respondents were unaware of the NNAP (89.0%). Only a third of respondents (35.1%) understood the funnel plot used to illustrate mortality.

CONCLUSIONS

Most patients were unaware of the NNAP and most did not understand the data on the website. Understanding of mortality data seemed to be related to respondents' educational level which would be important to keep in mind when planning how to depict mortality data.

Pediatric neurosurgical medulloblastoma outcomes in La Paz, Bolivia: How a Lower Middle-Income Country (LMIC) institution in South America compares to the United States

BACKGROUND

How pediatric medulloblastoma patients fare in Lower Middle-Income Country (LMICs) in South America is not well understood. Correspondingly, the aim of this study was to summarize the pediatric neurosurgical experience of an institution in La Paz, and compare outcomes to that of a generalized High Income Country (HIC) United States (US) experience.

METHODS

A retrospective review of all pediatric neurosurgical medulloblastoma patients at the Children's Hospital of La Paz, Bolivia (Hospital del Niño "Dr. Ovidio Aliaga Uria") between 2014 and 2023 was conducted and compared to a generalized US experience abstracted from the US National Cancer Database (NCDB) and National Inpatient Sample (NIS) databases. Categorical, continuous and survival data were statistically summarized and compared.

RESULTS

A total of 24 pediatric medulloblastoma patients underwent neurosurgical treatment at the Hospital del Niño. In this La Paz cohort, there were 15 (63%) males and 9 (38%) females, with a mean age of 5.6 years old at diagnosis. The majority of patients underwent subtotal resection (STR, 79%), while the remaining patients underwent biopsy only. Ten (42%) patients expired during their hospitalization, and mean length of stay overall was 39 days. Only 8 (33%) patients received adjuvant treatment after surgery. Median overall survival from diagnosis in the La Paz cohort was 1.9 months. Compared to the US databases, the La Paz cohort experienced significantly more emergency room admissions for surgery, less gross total resection, more STR, more return to operating room for ventriculoperitoneal shunting, more bacteremia, more tracheostomy procedures, more percutaneous gastrostomy placements, longer lengths of stay, less adjuvant chemotherapy, less radiation therapy, shorter follow-up, and ultimately, significantly shorter overall survival (all P < 0.050).

CONCLUSIONS

Pediatric neurosurgical medulloblastoma outcomes at the Children's Hospital of La Paz, Bolivia are significantly inferior to that of a generalized US experience. Future research is required to identify institution- and country-specific initiatives to improve discrepancies between institutions in LMICs in South America compared to HICs.

Quality of life in patients with unruptured intracranial aneurysms treated conservatively, before and after occlusion. A single center cohort study

Introduction

Rupture of intracranial aneurysms is the most frequent cause of subarachnoid hemorrhage and is associated with high morbidity. Recommendations for preventive treatment of unruptured aneurysms (UIAs) remain controversial due to inconsistent data on their natural history and the risks associated with treatment. The awareness of being diagnosed with one or more UIAs can provoke feelings of anxiety and psychosocial distress. Therefore, the impact of management on a patients' health perception and quality of life (QoL) is an essential factor to be considered in the treatment decision-making process.

Objective

The aim of this study was to assess and compare QoL in patients diagnosed with one or more UIAs depending on their treatment as well as their pre- or postoperative status.

Material and methods

Demographic and clinical data as well as results of the 15D quality of life (15D QoL) questionnaire of 189 patients were prospectively collected and retrospectively analyzed. Patients were categorized into different subgroups, depending on their treatment modalities (conservative, microsurgery or endovascular treatment) and their pre- or postoperative status at the time of completion of the questionnaire. Statistical analysis was performed to compare the different subgroups.

Results

Conservatively treated patients had similar mean 15D QoL scores as preoperative patients. Despite an initial postoperative QoL reduction and a trend towards recovery and even an improvement of QoL in the long term after UIA occlusion, neither clinically relevant nor statistically significant differences between preoperative and postoperative mean 15D QoL scores were observed.

Conclusions

Health-related QoL does not significantly change after treatment of UIAs when compared to the preoperative period. Further studies are needed to confirm long-term postoperative quality of life changes as well as treatment-related influencing factors on patients' quality of life.

Chat-GPT on brain tumors: An examination of Artificial Intelligence/Machine Learning's ability to provide diagnoses and treatment plans for example neuro-oncology cases

OBJECTIVE

Assess the capabilities of ChatGPT-3.5 and 4 to provide accurate diagnoses, treatment options, and treatment plans for brain tumors in example neuro-oncology cases.

METHODS

ChatGPT-3.5 and 4 were provided with twenty example neuro-oncology cases of brain tumors, all selected from medical textbooks. The artificial intelligence programs were asked to give a diagnosis, treatment option, and treatment plan for each of these twenty example cases. Team members first determined in which cases ChatGPT-3.5 and 4 provided the correct diagnosis or treatment plan. Twenty neurosurgeons from the researchers' institution then independently rated the diagnoses, treatment options, and treatment plans provided by both artificial intelligence programs for each of the twenty example cases, on a scale of one to ten, with ten being the highest score. To determine whether the difference between the scores of ChatGPT-3.5 and 4 was statistically significant, a paired t-test was conducted for the average scores given to the programs for each example case.

RESULTS

In the initial analysis of correct responses, ChatGPT-4 had an accuracy of 85% for its diagnoses of example brain tumors and an accuracy of 75% for its provided treatment plans, while ChatGPT-3.5 only had an accuracy of 65% and 10%, respectively. The average scores given by the twenty independent neurosurgeons to ChatGPT-4 for its accuracy of diagnosis, provided treatment options, and provided treatment plan were 8.3, 8.4, and 8.5 out of 10, respectively, while ChatGPT-3.5's average scores for these categories of assessment were 5.9, 5.7, and 5.7. These differences in average score are statistically significant on a paired t-test, with a p-value of less than 0.001 for each difference.

CONCLUSIONS

ChatGPT-4 demonstrates great promise as a diagnostic tool for brain tumors in neuro-oncology, as attested to by the program's performance in this study and its assessment by surveyed neurosurgeon reviewers.

Posterior median surgical approach to anterior sacral meningocele complicated by rectothecal fistula

In this case report, we aimed to describe the clinical presentation, surgical approach, and follow-up of a patient with rare anterior meningocele associated with rectothecal fistula. An 17-year-old female patient was admitted to the emergency department with meningitis. On further examinations, an anterior sacral meningocele accompanied by rectothecal fistula was detected. Appropriate antibiotic treatment was arranged and surgical plan was made with the pediatric surgery clinic. The patient underwent meningocele repair via posterior approach and colostomy operation. The patient did not experience any neurological issues after the surgery. The colostomy was reversed 3 months later, and third-month follow-up MRI showed complete regression of the meningocele sac with no neurological complications. Anterior meningocele accompanied by a rectothecal fistula is a rare and complicated case. Only seven cases of coexisting ASM and RTF have been reported in literature. Although both anterior and posterior approaches have been used for the treatment of ASM, the choice of treatment is essentially based on the patient's clinical and imaging findings.

The Current Landscape of Neurosurgical Oncology in Low-Middle-Income Countries (LMIC): Strategies for the Path Forward

OBJECTIVE

To promote global equity in research, innovation, and care, sharing knowledge and grasping current benchmarks is crucial. Despite LIC/LMIC constituting around 80% of the global population, their contribution to neurosurgery research is less than 5%. This study aims to assess the status of neurosurgical oncology in LIC/LMIC using published data, offering strategic insights for progress.

METHODS

Conducting a retrospective bibliometric analysis via PubMed and Scopus databases, we documented reports published (2015-2021) by neurosurgical department-affiliated investigators in LICs/LMICs. World Bank classifications identified LIC and LMIC. Reviewed papers underwent further scrutiny based on independent and associated keyword lists.

RESULTS

Our systematic approach revealed 189 studies from LMIC in 10 neurosurgery journals. Of these, 53% were case reports, with 88% focusing on brain pathologies and 12% on the spine. Intra-axial brain tumors (45.8%), extra-axial/skull base (38.4%), and metastasis (3.68%) were prominent. Among noncase report publications, surgical technique and outcome were common themes. India, Egypt, and Tunisia led in publications, with 94% appearing in journals with an impact factor below 5. No papers originated from LIC.

CONCLUSIONS

This study reinforces existing findings that data from LMIC inadequately represent their populations, impeding a comprehensive understanding of their neurosurgical oncology landscape. Language barriers and data collection difficulties contribute to this gap. Addressing these challenges could significantly enhance progress in shaping the future of neurosurgical oncology in these regions.

Exploring the neurosurgery training landscape in Pakistan: A trainee's perspective in resource-limited settings

Background

Shortage of neurosurgeons in Pakistan, one per 720,000 people, stems from a lack of trainees. Therefore, it is vital to assess the training experience, career opportunities, and satisfaction levels of neurosurgical trainees in Pakistan.

Methods

A nationwide survey was conducted, covering 22 CPSP-accredited neurosurgery training programs in Pakistan. Convenience sampling was utilized with a pilot tested questionnaire and responses were analyzed using STATA 15.

Results

The response rate was 98% (120/122) with 70.8% male and mean age of 30.4 ± 4.1 years. Training programs included teaching courses (79%) and journal club (66%); however, there was a lack of cadaver workshops (14%) and cranial model-based stimulation (22%). 67% of trainees lacked publications in indexed journals. 69% worked 50-100 h weekly, with 62% experiencing burnout due to workload and hours and a third reporting poor work-life balance. Trainees dedicated more to operating rooms (37%, 10-24 h/week) and clinics (34%, 24-48 h/week) compared to study (42%, <5 h/week) and research (64%, <5 h/week). Gender equality was rated poorly by 50%. Disparities emerged in subspecialty exposure, with over half of trainees lacking exposure to deep brain stimulation (67%), and epilepsy (75%). 52.5% of the training institutes did not offer fellowships and 64.1% of trainees planned to pursue fellowships abroad.

Conclusions

Steps need to be taken to improve working hours, gender equity, and increase simulation courses, diversify subspecialty exposure, and promote research initiatives.

Evaluation of severe traumatic brain injury referrals to the National Tertiary Neurosurgical Centre in the Republic of Ireland

BACKGROUND

Transfer of all severe TBI patients to a neurosurgical unit (NSU) has been advocated irrespective of levels of complexity and prognostic factors. Previous publications have suggested that only 50% of severe TBI patients in Ireland were managed in NSUs.

AIMS

This study aims to audit severe TBI referrals to the National Neurosurgical Centre, to evaluate reasons for nonacceptance, assess for differences in the transferred and not transferred cohorts and to analyse observed and expected mortality rates.

METHODS

Data on all patients with TBI referred in 2021 were prospectively collected using an electronic referral system. Patients with severe TBI (GCS ≤ 8 and AIS ≥ 3) were included and dichotomised into transferred and not transferred cohorts.

RESULTS

Of 118 patients referred with severe TBI, 45 patients (38.1%) were transferred to the neurosurgical centre. Patients in the transferred cohort were significantly younger (p < 0.001), had a higher GCS score (p < 0.001) and a lower proportion of bilaterally unreactive pupils (p < 0.001) compared to the not transferred cohort. 93% (68/73) of those not transferred were either >65 years old, or had bilaterally unreactive pupils, or both. Based on the IMPACT model, the observed to expected mortality ratios in the transferred and not transferred cohorts were 0.65 (95% CI 0.25-1.05) and 0.88 (95% CI 0.65-1.11) respectively.

CONCLUSION

The observed mortality rate for severe TBI in Ireland was similar to or better than expected mortality rates when adjusted for important prognostic factors. 93% of severe TBI patients not transferred to a neurosurgical centre were either elderly or had bilaterally unreactive pupils or both. These patients have an extremely poor prognosis and recommendation for transfer cannot be made based on current available evidence.

Hepatocellular carcinoma metastatic to the pituitary gland without an identifiable primary lesion

Hepatocellular carcinoma is one of the most common malignancies worldwide. However, brain metastases from this cancer are incredibly rare. While the hepatocellular carcinoma mortality rate in the United States has been increasing, hepatocellular carcinoma is rare among patients without underlying liver disease. Here we present a patient with a history of left optic nerve meningioma treated with stereotactic radiosurgery who presented with acute vision loss. Magnetic resonance imaging revealed an enhancing mass lesion in the region of the sella turcica. Neurosurgical histopathology revealed a metastatic lesion consistent with hepatocellular carcinoma. Systemic workup failed to identify a primary liver lesion.

Role and contributions of women in revolutionizing neurosurgery

We owe it to the women neurosurgeons for paving the way to a more gender-inclusive world of medicine. Their dedication and sacrifices have led them and their followers to scale unimaginable heights in terms of administrative positions, leadership, and academics. In today's scenario, it is safe to say that society has progressed considerably. Past years have seen an uprise in the number of females enrolling in a medical degree programme however, this proportion is highly distorted when it comes to specialties such as Neurosurgery. This disparity seems to be evolving and leveling out in all specialties, as more and more women are stepping out of their comfort zone and challenging the established standards of the society. It is with the collective efforts of all stakeholders and women that we see more women not only choosing such specialties which were previously uncharted terrain, but also leading organizations globally and excelling on the administrative and academic fronts. Veteran female surgeons have revolutionized neurosurgery and its subspecialties in unimaginable ways and the present as well as the future generation neurosurgeons continue to take inspiration from them and follow their footsteps. This paper has put together the contributions of female neurosurgeons in various subspecialties of neurosurgery as well as giving an account of the leadership and administrative positions served by women. We also shed light on the role of women as an academician and a researcher.

Pediatric head injuries: particularities and neurosurgical experience in a lower-middle income country

PURPOSE

To the best of our knowledge, this is the first study conducted in Tunisia on the neurosurgical management of child cranial trauma. The objectives of the present work were to identify the causes of pediatric head injuries, explore epidemiological and clinical specificities, and analyze the short- and long-term postoperative evolution.

METHODS

A retrospective review was conducted on one hundred children with head injuries over a five-year period at one of the largest neurosurgery departments in Tunisia. The collected data encompassed demographic information, clinical presentation features, neuroimaging characteristics, surgical management, complications, and outcomes.

RESULTS

Over a five-year period, we have found 118 children who have undergone surgery, representing an annual incidence of twenty-four children per year. The average age was 10 years. Falls emerged as the primary cause of childhood head injuries in our series, followed by road traffic accidents. The most frequently encountered initial sign was the loss of consciousness (52%), followed by headaches (28%), vomiting (25%), and seizures (8%). The average time between the accident and admission to the operating unit was 10 h. Various neurosurgeries were performed, with the evacuation of an epidural hematoma being the most common procedure. At a median follow-up of 24 months, the outcomes were favorable in 88% of cases.

CONCLUSION

The main prognostic factors for head trauma in children included age, circumstances of the accident, association with polytrauma, the initial Glasgow Coma Scale, the nature of the initial cerebral lesions, and the timeliness and quality of initial management.

Impact of remoteness and rurality on the treatment and survival of patients with glioblastoma in the north of Scotland

Background

The geographical catchment area served by the Neurosurgical Unit in Aberdeen, Scotland is the largest in the United Kingdom. We examined whether a distance-decay effect on survival exists for patients diagnosed with glioblastoma, who have to travel substantial distances for neurosurgical and oncological treatment in the north of Scotland.

Methods

Electronic medical records of adult patients with glioblastoma, referred for treatment between 2007 and 2018, who underwent surgical resection were reviewed. Travel time by car (as a measure of distance travelled) was calculated from the patients' home to their general practice (GP) and to their main neuro-oncological centre.

Results

There were 122 patients; 71 (58.2%) were male and the mean age was 57.8 years. The urban-rural split was 61.5% and 38.5%, respectively. Median driving time to the neuro-oncological centre was 36 min and to the GP this was 6 min. Most patients underwent either sub-total (49.6%) or gross total (46.3%) surgical resection. Post-operative treatments included: radiotherapy only (15.6%), chemotherapy only (6.6%), and chemotherapy with radiotherapy (63.1%). Temozolomide was used in 70.5% of patients. Seventeen patients did not receive any post-operative chemo-radiotherapy. The median survival time was 345 days. There was no statistically significant association between distance travelled and survival time in days. MGMT methylation status, extent of resection, Charlson co-morbidity index and treatment received significantly affected survival.

Conclusions

There was no evidence of disadvantage on survival time for patients living further from their neuro-oncological centre compared to those who live nearer.

The availability, access, challenges and advancements in neurosurgical care in Africa: a mini review

The availability and accessibility of neurosurgical care across Africa remains limited despite recent advancements. Overall, Africa accounts for 15% of the global neurosurgical disease burden but has access to less than 1% of neurosurgeons globally. While the number of neurosurgeons has increased in recent decades, huge workforce shortages remain, with the region facing the second-largest neurosurgical deficit. Access to adequate facilities and equipment is also lacking. Barriers like poverty, conflicts, and distance from care centres negatively impact patients' ability to access services. However, training programs like the World Federation of Neurosurgical Societies Rabat Training Center have contributed to building local capacity. Use of technologies like neuro-endoscopy is expanding access to more cost-effective interventions for conditions such as hydrocephalus. Undergraduate medical education is also seeing a rise in African students interested in neurosurgery. Despite these advancements, workforce shortfalls, inadequate infrastructure, and challenges posed by geopolitical instability continue to hinder the provision of comprehensive neurosurgical care. Limited research and funding discourage experienced surgeons from practicing in their home countries. Increased international collaboration, support for education, and tackling of structural issues are needed to continue strengthening Africa's neurosurgical capacity and reducing the disease burden. This narrative review aims to provide an overview of the current state of neurosurgery on the continent, highlight achievements, and identify persisting challenges.

Medical malpractice and epidural hematomas: a retrospective analysis of 101 cases in the United States

Background

Neurosurgeons face particularly high rates of litigation compared to physicians in other fields. Malpractice claims are commonly seen after mismanagement of life-threatening medical emergencies, such as epidural haematomas. Due to the lack of legal analysis pertaining to this condition, the aim of this study is to identify risk factors associated with litigation in cases relating to the diagnosis and treatment of epidural haematomas.

Materials and methods

Westlaw Edge, an online database, was used to analyze malpractice cases related to epidural haematomas between 1986 and 2022. Information regarding plaintiff demographics, defendant specialty, reason for litigation, trial outcomes, and payouts for verdicts and settlements were recorded. Comparative analysis between cases that returned a jury verdict in favour of the plaintiff versus defendant was completed.

Results

A total of 101 cases were included in the analysis. Failure to diagnose was the most common reason for litigation (n = 64, 63.4%), followed by negligent care resulting in an epidural haematoma (n = 44, 43.6%). Spine surgery (n = 29, 28.7%), trauma (n = 28, 27.7%), and epidural injection/catheter/electrode placement (n = 21, 20.8%) were the primary causes of haematomas. Neurosurgeons (n = 18, 17.8%) and anesthesiologists (n = 17, 16.8%) were the two most common physician specialties cited as defendants. Most cases resulted in a jury verdict in favour of the defense (n = 54, 53.5%). For cases ending in plaintiff verdicts, the average payout was $3 621 590.45, while the average payment for settlements was $2 432 272.73.

Conclusion

Failure to diagnose epidural haematomas is the most common reason for malpractice litigation, with neurosurgeons and anesthesiologists being the most common physician specialties to be named as defendants. More than half of all cases returned a jury verdict in favour of the defense and, on average, settlements proved to be more cost-effective than plaintiff verdicts.

Incidence, risk factors and impact of anemia after elective neurosurgery: A retrospective cohort study

Objectives

Anemia after surgery is common and is associated with adverse clinical outcomes. Understanding the incidence and risk factors for postoperative anemia is important to reduce anemia-related complications and blood transfusion. There is lack of data regarding postoperative anemia and its contributing factors in neurosurgery. This study evaluates the incidence and risk factors of postoperative anemia, and its impact on clinical outcomes.

Methods

This was a single centre, retrospective study of patients who underwent elective neurosurgery over seven months. Data regarding age, gender, body mass index, American Society of Anesthesiologists (ASA) physical status, diagnosis, surgery, preoperative hemoglobin, surgery duration, intraoperative blood loss and red blood cell (RBC) transfusion, dose of tranexamic acid, intraoperative fluid balance, years of surgeon's experience, postoperative hemoglobin, postoperative RBC transfusion, Glasgow Coma Scale (GCS) score at hospital discharge, and duration of postoperative intensive care unit and hospital stay were collected. Logistic regression was used to identify predictors of postoperative anemia.

Results

The incidence of postoperative anemia was 11.3% (116/1025). On univariate analysis; age, preoperative hemoglobin, surgery duration, gender, ASA grade, surgery type, and surgeon's experience were associated with postoperative anemia. Lower preoperative hemoglobin (p<0.001) and non-tumor surgery (p<0.001) were predictive of postoperative anemia on multivariate analysis. Postoperative anemia resulted in increased RBC transfusion (p<0.001) and lower GCS score at discharge (p=0.012).

Conclusions

Atleast one in ten patients undergoing elective neurosurgery develop postoperative anemia. Lower preoperative hemoglobin and non-tumor surgery predict anemia. Anemia results in increased RBC transfusion and lower discharge GCS score.

The frailty-driven predictive model for failure to rescue among patients who experienced a major complication following cervical decompression and fusion: an ACS-NSQIP analysis of 3,632 cases (2011-2020)

BACKGROUND CONTEXT

Preoperative risk stratification for patients considering cervical decompression and fusion (CDF) relies on established independent risk factors to predict the probability of complications and outcomes in order to help guide pre and perioperative decision-making.

PURPOSE

This study aims to determine frailty's impact on failure to rescue (FTR), or when a mortality occurs within 30 days following a major complication.

STUDY DESIGN/SETTING

Cross-sectional retrospective analysis of retrospective and nationally-representative data.

PATIENT SAMPLE

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for all CDF cases from 2011-2020.

OUTCOME MEASURES

CDF patients who experienced a major complication were identified and FTR was calculated as death or hospice disposition within 30 days of a major complication.

METHODS

Frailty was measured by the Risk Analysis Index-Revised (RAI-Rev). Baseline patient demographics and characteristics were compared for all FTR patients. Significant factors were assessed by univariate and multivariable regression for the development of a frailty-driven predictive model for FTR. The discriminative ability of the predictive model was assessed using a receiving operating characteristic (ROC) curve analysis.

RESULTS

There were 3632 CDF patients who suffered a major complication and 7.6% (277 patients) subsequently expired or dispositioned to hospice, the definition of FTR. Independent predictors of FTR were nonelective surgery, frailty, preoperative intubation, thrombosis or embolic complication, unplanned intubation, on ventilator for >48 hours, cardiac arrest, and septic shock. Frailty, and a combination of preoperative and postoperative risk factors in a predictive model for FTR, achieved outstanding discriminatory accuracy (C-statistic = 0.901, CI: 0.883-0.919).

CONCLUSION

Preoperative and postoperative risk factors, combined with frailty, yield a highly accurate predictive model for FTR in CDF patients. Our model may guide surgical management and/or prognostication regarding the likelihood of FTR after a major complication postoperatively with CDF patients. Future studies may determine the predictive ability of this model in other neurosurgical patient populations.

Evolution of neurosurgical advances and nuances in medulloblastoma therapy

Medulloblastoma, the most common malignant brain tumor in children, presents a complex treatment challenge due to its propensity for infiltrative growth within the posterior fossa and its potential attachment to critical anatomical structures. Central to the management of medulloblastoma is the surgical resection of the tumor, which is a key determinant of patient prognosis. However, the extent of surgical resection (EOR), ranging from gross total resection (GTR) to subtotal resection (STR) or even biopsy, has been the subject of extensive debate and investigation within the medical community. Today, the impact of neurosurgical EOR on the prognosis of medulloblastoma patients remains a complex and evolving area of investigation. The conflicting findings in the literature, the challenges posed by critical surrounding anatomical structures, the potential for surgical complications and neurologic morbidity, and the nuanced interactions with molecular subgroups all contribute to the complexity of this issue. As the field continues to advance, the imperative to strike a delicate balance between maximizing resection and preserving quality of life remains central to the management of medulloblastoma patients.

Utilization of Locum Tenens in Neurosurgery

INTRODUCTION

Despite its rising popularity, little has been described about locum tenens employment (locums) in neurosurgery. This study provides the first nationwide overview of the locums neurosurgery experience.

METHODS

An anonymous online survey examined practice characteristics of respondents, extent of and satisfaction with locums, motivations for pursuing locums, case volumes, agencies used, compensation, and positive/negative aspects of experiences. Responses were collected between November 2020 and February 2021.

RESULTS

Response rate for the 1852 neurosurgeons who opened the survey request was 4.9%; 36 of 91 respondents had previously worked locums and were commonly motivated by compensation or transitioning to new jobs or retirement. In our response group, 92% of locums respondents had taken more than one position and 47% had taken more than 10. Neurosurgeons performing <200 cases/year were significantly more likely to have also worked locums than those performing >200 cases/year (41.6% locums, 12.7% non-locums, P = 0.001). Responses showed that 69% of locums respondents earned $2000-$2999/day and 16% earned >$3500/day. Nearly 78% of locums respondents were satisfied with their experience(s) and 86% would take another future locums position. Being in practice for >15 years was significantly associated with satisfaction with locums (P = 0.03). Reported flaws included unfamiliarity with hospitals, limited continuity of care, credentialing burdens, and inadequate travel compensation.

CONCLUSIONS

Locums is utilized by neurosurgeons across multiple practice types and may serve to complement workloads or "fill in gaps" between longer-term employment. Overall, locums neurosurgeons are well compensated, and the majority are satisfied with their experience(s). Inevitably, flaws still exist with locums employment, which may be the focus of organized efforts aiming to improve the experience.

Assessing Diversity, Equity, and Inclusion in Patient-Facing Websites in Neurosurgical Departments in the United States

BACKGROUND

Patient-facing websites serve as essential platforms for disseminating information, engaging with patients, and increasing access to neurosurgical resources and services. Diversity, Equity, and Inclusion are at the forefront of issues facing the field of neurosurgery, especially concerning race and gender disparities in regards to providers in the field.

METHODS

Data were collected in regards to the race and gender of patients and providers displayed on the neurosurgery department's patient-facing website in addition to accommodations for disabilities, decreased ability to pay, and language.

RESULTS

Patients who were White were depicted more commonly than those of color (69% vs. 31%, P < 0.00001). White patients also were over-represented when compared with the average demographics of the communities in which the hospitals served (P = 0.03846). Neurosurgical providers who were White outnumbered those of color (70% vs. 30%, P < 0.00001). The racial depiction of providers was comparable with racial disparities currently observed in neurosurgery (P = 0.59612). Female neurosurgery providers were seen less than male providers on patient-facing websites (P < 0.00001) but were seen more commonly on patient-facing websites than the percentage of practicing neurosurgeons they currently comprise (28% vs. 8%, P < 0.00001).

CONCLUSIONS

The results of this study suggest that patient-facing websites of neurosurgical departments are an area of improvement in regards to Diversity, Equity, and Inclusion in the field of neurosurgery. Disparities are noted in regards to the racial depiction of patients and further call to attention racial and gender disparities in the field of neurosurgery.