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.

Revitalizing neurosurgical frontiers: The EANS frontiers in neurosurgery committee's strategic framework

Introduction

The field of neurosurgery faces challenges with the increasing involvement of other medical specialties in areas traditionally led by neurosurgeons. This paper examines the implications of this development for neurosurgical practice and patient care, with a focus on specialized areas like pain management, peripheral nerve surgery, and stereotactic radiosurgery.

Research question

To assess the implications of the expanded scope of other specialties for neurosurgical practice and to consider the response of the EANS Frontiers in Neurosurgery Committee to these challenges.

Materials and methods

Analysis of recent trends in neurosurgery, including the shift in various procedures to other specialties, demographic challenges, and the emergence of minimally invasive techniques. This analysis draws on relevant literature and the initiatives of the Frontiers in Neurosurgery Committee.

Results

We explore a possible decrease in neurosurgical involvement in certain areas, which may have implications for patient care and access to specialized neurosurgical interventions. The Frontiers in Neurosurgery Committee's role in addressing these concerns is highlighted, particularly in terms of training, education, research, and networking for neurosurgeons, especially those early in their careers.

Discussion and conclusion

The potential decrease in neurosurgical involvement in certain specialties warrants attention. This paper emphasizes the importance of carefully considered responses by neurosurgical societies, such as the EANS, to ensure neurosurgeons continue to play a vital role in managing neurological diseases. Emphasis on ongoing education, integration of minimally invasive techniques, and multidisciplinary collaboration is essential for maintaining the field's competence and quality in patient care.

The Efficacy of Traumatic Brain Injury Treatment by Neurotrauma Specialists

Objective

Since the establishment of Regional Trauma Centers (RTCs) in Korea, significant efforts have been made to improve the quality of care for patients with trauma. Simultaneously, the Department of Neurosurgery assigned neurotrauma specialists to RTCs to provide specialized care to patients with traumatic brain injury (TBI). In this study, we sought to determine whether neurotrauma specialists, compared to general neurosurgeons, could make a significant difference in treatment outcomes of patients with TBI.

Methods

In total, 156 patients with acute TBI who required decompression were included. We reviewed their records and compared the characteristics, outcomes, and prognosis of those who received surgical treatment from either neurotrauma specialists or general neurosurgeons at our institution.

Results

A significant difference was observed between treatment by trauma neurosurgery specialists and general neurosurgeons in time to surgery, with trauma specialists experiencing shorter surgical delays. However, no significant differences existed in mortality rates or Extended Glasgow Outcome Scale scores. Univariate and multivariable regression analyses revealed that lower Glasgow Coma Scale scores, an abnormal pupil reflex, larger transfusion volume, and prolonged time from emergency room admission to surgery were associated with high mortality rates.

Conclusion

Neurotrauma specialists can provide prompt surgical treatment to patients with TBI compared to general neurosurgeons. Our study did not reveal a significant difference in outcomes between the two groups. However, it is clear that rapid decompression is effective in patients with impending brain herniation. Therefore, the effectiveness of neurotrauma specialists needs to be confirmed through further systematic studies.

Recognition and Practice of Hypopituitarism After Traumatic Brain Injury and Subarachnoid Hemorrhage in Japan: A Survey

INTRODUCTION

Individuals with traumatic brain injury (TBI) or subarachnoid hemorrhage (SAH) are at a high risk of hypopituitarism, and should benefit from early diagnosis and management. However, data on awareness, attitudes, and practices of physicians treating hypopituitarism post-TBI/SAH are limited. The objectives of this study were to gain an understanding of the awareness of Japanese neurosurgeons and endocrinologists towards hypopituitarism post-TBI/SAH and the need for pituitary function assessments in these patients; and to assess the practices and perspectives of these specialists on screening patients with this condition.

METHODS

An observational, cross-sectional study was performed that included a Web-based survey of practicing neurosurgeons managing ≥ 1 new patients with TBI/SAH per year or endocrinologists with ≥ 1 new patients per year with a history of TBI/SAH.

RESULTS

Of the 316 respondents (201 neurosurgeons [male, 95.5%]; 115 endocrinologists [male, 77.4%]), 75.6% of neurosurgeons and 81.7% of endocrinologists were aware of the probable occurrence of hypopituitarism post-TBI/SAH, and 79% neurosurgeons and 93.8% endocrinologists considered pituitary function impairment after TBI/SAH to be either very important or important. Hypopituitarism after TBI/SAH was recognized as an important concern by both neurosurgeons (79%) and endocrinologists (93.8%). Although many respondents agreed that such patients remain undiagnosed and untreated, pituitary function assessment post-TBI/SAH has only been performed to a limited extent. The awareness that post-TBI/SAH hypopituitarism is often transient and can progress over several weeks or months was lower in neurosurgeons (46.8%) than in endocrinologists (66.1%).

CONCLUSIONS

The level of awareness of hypopituitarism post-TBI/SAH was lower among Japanese neurosurgeons than among endocrinologists. Educational programs and detailed guidance for the diagnosis and treatment of hypopituitarism post-TBI/SAH are warranted.

Geographical Distribution of Neurosurgeons and Emergency Neurosurgical Services in Pakistan

BACKGROUND AND OBJECTIVE

According to the World Federation of Neurosurgical Societies (WFNS), a minimum neurosurgery workforce density should be 1 per 200,000 population for optimum access to neurosurgical care. Pakistan lags behind in the number of neurosurgeons, and disproportionate geographical distribution further increases disparity. Our objective was to geographically map the density of neurosurgeons and emergency neurosurgical services (ENS) in Pakistan.

METHODS

This survey was circulated among 307 neurosurgeons. Data were analyzed using SPSS v21. The number of neurosurgeons and ENS were plotted on the population density map using ArcGIS Pro 3.0.0 software.

RESULTS

Three hundred and seven neurosurgeons working at 74 centers responded to our survey (93.3% coverage). The current density of neurosurgeons in Pakistan is 0.14/100,000. The 2 more populous provinces, Punjab and Sindh, have 42.3% (130) and 35.8% (110) neurosurgeons, respectively. They also housed nearly 3 quarters of all the neurosurgery centers in urban districts. Karachi and Lahore accommodate 135 (44%) of all the country's neurosurgeons, having 0.29 and 0.51 neurosurgeons/100,000 respectively. Management of traumatic brain injury is offered at 65 centers (87.8%). Nearly all centers are equipped with computed tomography (CT) scan machine (74; 97%), but magnetic resonance imaging (MRI) facility is available at 55 (72%) centers and 37 (49%) centers have angiography suites. Sixty nine centers (93.2%) have C-arm fluoroscopes available.

CONCLUSIONS

The geographical mapping of neurosurgeons and neurosurgical facilities is highly skewed towards urban centers, increasing disparity in access to timely neurosurgical emergency services. Four times more neurosurgeons are required in Pakistan to bridge the gap in neurosurgical workforce.

Surgical anatomy of hypoglossal canal for various skull base surgeries

PURPOSE

Anatomical knowledge of the hypoglossal canal is very important in relation to drilling of occipital condyle, jugular tubercle etc. So, this study was conducted to identify various morphometric and morphological features of the hypoglossal canal and its distance from adjacent structures relative to stable and reliable anatomic landmarks.

METHODS

The study was performed on 142 hypoglossal canals of 71 adult human dry skulls. The parameters measured were the transverse, vertical diameter, depth of the hypoglossal canal. The distances from the hypoglossal canal to the foramen magnum, occipital condyle and jugular foramen were also noted. In addition, the different locations of the hypoglossal canal orifices in relation to the occipital condyle were assessed. The different shapes and types of the hypoglossal canal were also noted.

RESULTS

There was significant difference (p < 0.05) in measurements taken on the right and left sides in males and females. The intracranial orifice of hypoglossal canal was present in middle 1/3rd in 100% of occipital condyle for both genders. The extracranial orifice of the hypoglossal canal was found to be in the anterior 1/3rd in 99% and 93.7% for male and female, respectively. Simple hypoglossal canal with no traces of partition was found to be more in males and females. The most common shape noted was oval both in males and females (71.8% and 68.7% respectively).

CONCLUSION

The results of the dimensions of the hypoglossal canal and its distance from other bony landmarks will be helpful for neurosurgeons to plan which surgical approaches should be undertaken while doing various surgeries in posterior cranial fossa.

Morphometric analysis of the main brain sulci and clinical implications: Radiological and cadaveric study

Objective

Sulci and gyri of the cerebrum can be easily identified with the aid of radiology but are difficult to locate during surgical operations, owing to anatomical variations and the surgical approach of the sulci through a small aperture. Therefore, this study was performed to locate the main sulci of the brain by using various anatomical landmarks in cadaveric brain specimens and CT scan images.

Methods

In 31 cadaveric brain specimens (17 right and 14 left hemispheres) from people of unknown sex, 21 parameters associated with important sulci of the brain were studied. CT scan images for 150 patients in three age groups were examined. The patient IDs were categorized into 50 patients in each of the following age groups: 20-40 yr, 41-60 yr and 61-80 yr. Ten parameters were studied. The data were statistically analyzed in SPSS software.

Results

In the cadaveric brain specimens, comparisons of right and left hemispheres indicated that only the posterior part of the calcarine sulcus showed a significant difference (p = 0.0394). In CT scans within each age group, comparison of the right and left sides in males and females showed significant differences for many parameters (e.g., calcarine sulcus to occipital pole: right p = 0.0025; left p = 0.0009). Comparisons between male and female parameters also showed significant differences.

Conclusion

This study aids in identifying the important functional areas of the brain situated near the sulci, given that the sulci are connected to the gyral functions and act as a barrier for the gyri. The findings may facilitate neurosurgery operations.

Role of Neurosurgeons in the Treatment of Acute Ischemic Stroke in the Emergency Room

OBJECTIVE

With the recent increase in mechanical thrombectomy (MT) for acute ischemic stroke (AIS), the role of neurosurgeons in AIS treatment has become increasingly important. This study aimed to assess the outcomes of patients with AIS treated by neurosurgeons and neurologists in the emergency room (ER) of a tertiary hospital in South Korea.

METHODS

From January 2020 to June 2021, 536 patients with AIS within 24 hours of symptom onset were admitted to our hospital via the ER. Based on the type of doctors who provided initial care for AIS in the ER, patients were divided into two groups : (a) neurosurgeon group (n=119, 22.2%) and (b) neurologist group (n=417, 77.8%).

RESULTS

Intravenous tissue plasminogen activator (tPA) was administered in 82 (15.3%) of 536 patients (n=17 [14.3%] in the neurosurgeon group and n=65 [15.6%] in the neurologist group). The door-to-tPA time was not significantly different between both groups (median, 53 minutes; interquartile range [IQR], 45-58 vs. median, 54 minutes; IQR, 46-74; p=0.372). MT was performed in 69 patients (12.9%) (n=25, 36.2% in the neurosurgeon group and n=44, 63.8% in the neurologist group). The neurosurgeon group achieved a shorter door-to-puncture time than the neurologist group (median, 115 minutes; IQR, 107-151 vs. median, 162 minutes; IQR, 117-189; p=0.049). Good clinical outcomes (3-month modified Rankin Scale 0-2) did not differ significantly between the two groups (96/119 [80.7%] vs. 322/417 [77.2%], p=0.454).

CONCLUSION

The neurosurgeon group showed similar door-to-treatment time and clinical outcomes to the neurologist group in patients with AIS in the ER. This study suggests that neurosurgeons have comparable abilities to care for patients with AIS in the ER.

A Year of Pandemic-Comparison of Depression Among Neurosurgeons After the Advent of the COVID-19 Vaccine

Objective

To determine factors associated with anxiety and depression among neurosurgeons after vaccination during the coronavirus disease 2019 (COVID-19) pandemic.

Methods

An online survey was completed by neurosurgeons worldwide over 4 weeks. Depression in neurosurgeons was assessed by the 20-item self-reporting questionnaire.

Results

A total of 534 responses were received and analyzed. Almost half of the respondents were from Asia (50.9%), followed by Europe (38.8%). The majority of the respondents were <40 years old (88%), and almost two thirds were trainees (62.2%). Half of the respondents worked in departments with <40 beds (50.7%), and the majority were practicing in the private sector (72.5%). Most of the respondents (85.8%) had COVID-19–positive colleagues in their department, and 64% had exposure to a COVID-19–positive colleague, family member, and/or patient. More than half of the respondents were exposed to infected patients and/or colleagues, and almost half (43.1%) underwent COVID-19 testing when exposed. Nearly half of the respondents underwent COVID-19 testing more than twice (52.4%). Of respondents, 83% had received at least the first dose of the vaccine. The odds of depression among vaccinated respondents were found to be significantly less than among unvaccinated respondents in the univariable model.

Conclusions

Among health care workers, neurosurgeons are one of the groups indirectly affected by the pandemic. Adaptation to the new normal and advent of vaccines is speculated to control psychological distress among all groups of health care workers, including neurosurgeons. We found that odds of depression among vaccinated people were lower than among people who were not vaccinated.

Reasons for delayed spinal cord decompression in individuals with traumatic spinal cord injuries in Iran: A qualitative study from the perspective of neurosurgeons

PURPOSE

The median time from the event leading to the spinal cord injury (SCI) to the time of decompressive surgery is estimated to be 6.9 days in Iran, which is much longer than the proposed ideal time (less than 24 h) in published guidelines. The current qualitative study aimed to determine the reasons for the observed decompression surgery delay in Iran from the perspective of neurosurgeons.

METHODS

This qualitative study is designed to perform content analysis on the gathered data from face-to-face semi-structured interviews with 12 Iranian neurosurgeons.

RESULTS

The findings of the current study suggest that patient-related factors constitute more than half of the codes extracted from the interviews. Overall, the type of injury, presence of polytrauma, and surgeons' wrong attitude are the main factors causing delayed spinal cord decompression in Iranian patients from the perspective of neurosurgeons. Other notable factors include delay in transferring patients to the trauma center, delay in availability of necessary equipment, and scarce medical personnel.

CONCLUSION

In the perspective of neurosurgeons, the type of injury, presence of polytrauma, and surgeons' wrong attitude are the leading reasons for delayed decompressive surgery of individuals with SCI in Iran.

'Every patient is like my child': pediatric neurosurgeons' relational and emotional bonds with their patients and families

PURPOSE

To explore the relational and emotional components of the surgeon-patient relationship from the perspective of practicing pediatric neurosurgeons in the field.

MATERIALS AND METHODS

The study utilized the Grounded Theory Method of data collection and analysis. 26 pediatric neurosurgeons from 12 countries were interviewed using video-conferencing technology.

RESULTS

Pediatric neurosurgeons find meaning, joy and pleasure in the relationships they form with their patients and their families, while also experiencing difficult and painful emotions when these patients do not do well. Four themes emerged from the analysis that include having a relational attachment to patients, forming bonds with the parents/caregivers of these patients, dealing with patient suffering, death and complications, and communicating bad news to parents.

CONCLUSIONS

Pediatric neurosurgeons develop deep and enduring bonds with their patients and their families. These relationships are an integral part of what brings meaning and joy to their work, and simultaneously, are one of the most significant emotional challenges of their careers. . Training neurosurgical fellows should include pedagogical modules about the relational and emotional dimensions of their work, with a specific and dedicated focus on communicating bad news.

A Study on Work Intensity, Work-Life Balance, and Burnout among Korean Neurosurgeons after the Enactment of the Special Act on Korean Medical Residents

OBJECTIVE

Since the enactment of the Special Act on Korean Medical Residents, neurosurgeons working at training hospitals have been performing the duties of residents, in addition to their existing patient care responsibilities, which include surgery, education, and research. This study explores the relationships between work intensity, work-life balance, and burnout experienced by Korean neurosurgeons.

METHODS

The participants (n=451) were neurosurgeons working at training hospitals throughout Republic of Korea. Data on socio-demographic characteristics (including objective and subjective work environment), work intensity, work-life balance, and burnout were gathered using self-report questionnaires completed between March 1 and December 20, 2019. The data were analyzed using descriptive statistics, independent samples t-tests, one-way analysis of variance, Pearson's correlations, and multiple regression analysis. IBM SPSS Statistics for Windows, version 25 (IBM Corp., Armonk, NY, USA) was used for the analyses.

RESULTS

The work intensity, work-life balance, and burnout levels of neurosurgeons were 3.95, 3.57 (on a scale from 1 to 5) and 4.60 (on a scale from 1 to 7); and 280 (62.1%) of 451 neurosurgeons were found to be experiencing burnout. By controlling for the socio-demographic characteristics, the effects of work intensity and work-life balance on burnout were analyzed. Work intensity (B=0.314), work-life balance-family and leisure (B=0.216), work-life balance-growth (B=0.147), job stress (B=0.133), and satisfaction with human relationships (B=-0.069) were shown to be significant (all p<0.05), and they were found to affect burnout in the abovementioned order. The overall explanatory power was 58.3% (p<0.05), and the explanatory power with the addition of independent variables such as work intensity and work-life balance was 14.5% (p<0.05).

CONCLUSION

This study showed that Korean neurosurgeons working at training hospitals experienced a high level of work intensity and job stress, and low work-life balance. Additionally, nearly half of the neurosurgeons were found to experience burnout related to factors such as work intensity, work-life balance, job stress, and satisfaction with human relationships. In particular, these factors seem to have deteriorated further after the implementation of the Special Act on Korean Medical Residents. These very high levels of burnout among Korean neurosurgeons who care for patients with both brain and spinal diseases may have a very important impact on patients' health. Therefore, it is recommended that the Korean Neurosurgical Society and the Korean government make efforts to improve the factors that affect burnout among Korean neurosurgeons.

How Do Pediatric Neurosurgeons Make Intraoperative Decisions?

OBJECTIVE

The purpose of this research was to explore the processes by which pediatric neurosurgeons make intraoperative decisions when they encounter something unexpected or uncertain while they are operating.

METHODS

The study used the grounded theory method of data collection and analysis. Twenty-six pediatric neurosurgeons (PNs) from 12 countries were interviewed about the process by which they make intraoperative decisions. Data were analyzed line by line, and constant comparison was used to examine relationships within and across codes and categories.

RESULTS

PNs described a complex process that existed along a spectrum in making intraoperative decisions. Three types of response processes emerged from the analysis: 1) internal processing, with the themes of getting oneself under control and performing control for the surgical team; 2) action processes that included the themes of stabilizing the patient, responding intuitively/automatically when making decisions, and shifting surgical strategies; and 3) analytical processing that involved assessing the situation, consulting with colleagues and the family of the patient when making intraoperative decisions.

CONCLUSIONS

The findings from this study contribute novel information on PNs' intraoperative decision making processes and can be used to train resident neurosurgeons about the various components involved in these processes. This research suggests that new models of decision making are needed within the medical and neurosurgical context and inspire a new set of questions about the process by which surgeons make life and death decisions in the operating room.

Should neurosurgeons continue to work in the absence of personal protective equipment during the COVID-19 era?

The COVID-19 pandemic has resulted in a widespread shortage of personal protective equipment (PPE). Many healthcare workers, including neurosurgeons, have expressed concern about how to safely and adequately perform their medical responsibilities in these challenging circumstances. One of these concerns revolves around the pressing question: should providers continue to work in the absence of adequate PPE? Although the first peak of the COVID-19 crisis seems to have subsided and supply of PPE has increased, concerns about insufficient PPE availability remain. Inconsistent supply, limited efficacy, and continued high demand for PPE, combined with the continued threat of a second COVID-19 wave, mean that the issues surrounding PPE availability remain unresolved, including a duty to work. This paper offers an ethical investigation of whether neurosurgeons should perform their professional responsibilities with limited availability of PPE. We evaluate ethical considerations and conflicting duties and thereby hope to facilitate providers in making a well-considered personal and moral decision about this challenging issue.

Mistreatment, discrimination and burn-out in Neurosurgery

OBJECTIVE

Issues concerning harassment, bullying and discrimination are not unknown to medical specialties and are likely to be present in neurosurgery as well. The aim of this study was to estimate the extent to which neurosurgeons are faced with issues pertaining to this mistreatment.

METHODS

A survey consisting of fourteen questions was distributed among members of the Congress of Neurological Surgeons (CNS). The survey consisted of three parts: 1) demographics; 2) exposure to mistreatment; 3) experienced burnout symptoms.

RESULTS

In total 503 out of the 5665 approached CNS members filled in a survey (response rate 8.9 %). Respondents consisted for 85.9 % out of neurosurgeons and for 13.9 % out of residents. Overall, 61.4 % of the respondents was a victim of form of abusive behavior, while 47.9 % was a victim of at least one form of discrimination. Most reported sources of these mistreatments were other neurosurgeons or (family of) patients. Overall, 49.9 % of the respondents experienced burnout symptoms. Multivariable logistic regression analysis showed that female respondents had higher odds of being a victim of abuse (OR 2.5, 95 % CI 1.4-4.6). Female respondents (OR 19.8, 95 % CI 8.9-43.9) and ethnic minorities (OR 3.8, 95 % CI 2.3-6.2) had higher odds of being a victim of discrimination. Furthermore, victims of abuse were at higher odds (OR 1.7, 95 % CI 1.1-2.6) of having burnout symptoms.

CONCLUSIONS

Mistreatment and experiencing burnout symptoms frequently occurs among neurosurgeons and residents.

Geospatial Distribution of Neurosurgeons Age 60 and Older Relative to the Spread of COVID-19

OBJECTIVE

To perform an ecological study to analyze the geospatial distribution of neurosurgeons ≥60 years old and compare these data with the spread of 2019 novel coronavirus disease (COVID-19) across the United States.

METHODS

Data regarding distribution of COVID-19 cases were collected from the Environmental Systems Research Institute, and demographic statistics were collected from the American Association of Medical Colleges 2019 State Workforce Reports. These figures were analyzed using geospatial mapping software.

RESULTS

As of July 5, 2020, the 10 states with the highest number of COVID-19 cases showed older neurosurgical workforce proportions (the proportion of active surgeons ≥60 years old) of 20.6%-38.9%. Among states with the highest number of COVID-19 deaths, the older workforce proportions were 25.0%-43.4%. Connecticut demonstrated the highest with 43.4% of neurosurgeons ≥60 years old.

CONCLUSIONS

Regional COVID-19 hotspots may coincide with areas where a substantial proportion of the neurosurgical workforce is ≥60 years old. Continuous evaluation and adjustment of local and national clinical practice guidelines are warranted throughout the pandemic era.

Deployment of Neurosurgeons at the Warfront Against Coronavirus Disease of 2019 (COVID-19)

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has taken the world by storm, especially the health care system. Medical practitioners of all specialties are being assigned to treat patients of COVID-19. In this article, two authors (T.V. and N.G.) from the Department of Neurosurgery who were deployed in the COVID-19 testing ward between April 25 and May 31, 2020 share their experience.

METHODS

A prospective observational study was conducted including all those who were admitted in this ward. The patients were studied according to their demographic profiles, diagnoses, admitting departments, travel history, and presence/absence of COVID-19-related symptoms. Relevant history regarding occupation, contact with patient with known COVID-19, and comorbid illness was noted. Those who tested positive for COVID-19 were studied further. The data from the institute's official record were updated until August 14, 2020.

RESULTS

During the study period, there were 256 admissions in the ward, of whom 148 (92 male, 56 female) were patients and 108 were patients' attendants/relatives. Most patients were admitted under the departments of internal medicine (33, 22.3%) and general surgery (19, 12.8%). Of 148 patients, 46 (31.1%) were admitted as they were planned for a surgery/intervention. Among 148 patients, 29 (19.6%) had history of travel to or were residents of a red zone, 4 (2.7%) had history of contact with a confirmed case of COVID-19, whereas 6 (4.1%) were health care workers. One hundred four patients (70.2%) showed no COVID-19-related symptoms. Thirty-four patients (22.9%) had associated comorbid conditions. Eight patients (5 male, 3 female) with mean age of 37.6 years (range 4-69 years) tested positive for COVID-19.

CONCLUSIONS

The authors share their experience and their institute's protocol in various facets during this war against COVID-19 pandemic. Preadmission and presurgical testing of patients is important in preventing the spread of the disease amongst health care workers.

Neurosurgery versus orthopedic surgery: Who has better access to minimally invasive spinal technology?

Background:

Our aim was to evaluate differences in neurosurgeons versus orthopedists access to technologies needed to perform minimally invasive spine surgeries (MISS) in Latin America.

Methods:

We sent a survey to members of AO Spine Latin America (January 2020), and assessed the following variables; nationality, level of hospital (primary, secondary, and tertiary), number of spinal operations performed per year, spinal pathologies addressed, the number of minimally invasive spine operations performed/year, and differences in access to MISS spinal technology between neurosurgeons and orthopedists.

Results:

Responses were returned from 306 (25.6) members of AO Spine Latin America representing 20 different countries; 57.8% of respondents were orthopedic surgeons and 42.4% had over 10 years of experience. Although both specialties reported a lack of access to most of the technologies, the main difference between the two was greater utilization/access of neurosurgeons to operating microscope (e.g., 84% of the neurosurgeons vs. 39% of orthopedic spine surgeons).

Conclusion:

Although both specialties have limited access to MISS spinal technologies, orthopedic spine surgeons reported significantly lower access to operating microscopes versus neurosurgeons (P < 0.01).

Characteristics of Reported Industry Payments to Neurosurgeons: A 5-Year Open Payments Database Study

OBJECTIVE

The aim of this study was to characterize the payments made by medical industry to neurosurgeons from 2014 to 2018.

METHODS

A retrospective study was performed from January 1, 2014 to December 31, 2018 of the Open Payments Database. Collected data included the total number of industry payments, the aggregate value of industry payments, and the mean value of each industry payment made to neurosurgeons per year over the 5-year period.

RESULTS

A total of 105,150 unique surgeons, with 13,668 (12.99%) unique neurosurgeons, were identified to have received an industry payment during 2014-2018. Neurosurgeons were the second highest industry-paid surgical specialty, with a total 421,151 industry payments made to neurosurgeons, totaling $477,451,070. The mean average paid amount per surgeon was $34,932 (±$936,942). The largest proportion of payments were related to food and beverage (75.5%), followed by travel and lodging (14.9%), consulting fees (3.5%), nonconsulting service fees (2.1%), and royalties or licensing (1.9%), totaling 90.4% of all industry payments to neurologic surgeons. Summed across the 5-year period, the largest paid source types were royalties and licensing (64.0%; $305,517,489), consulting fees (11.8%; $56,445,950), nonconsulting service fees (7.3%; $34,629,109), current or prospective investments (6.8%, $32,307,959), and travel and lodging (4.8%, $22,982,165).

CONCLUSIONS

Our study shows that over the most recent 5-year period (2014-2018) of the Centers for Medicare and Medicaid Services Open Payments Database, there was a decreasing trend of the total number of payments, but an increasing trend of the total amount paid to neurosurgeons.

In Memoriam: A Memoir for Our Fallen "Heroes"

Even though neurosurgeons exercise these enormous and versatile skills, the COVID-19 pandemic has shaken the fabrics of the global neurosurgical family, jeopardizing human lives, and forcing the entire world to be locked down. We stand on the shoulders of the giants and will not forget their examples and their teachings. We will work to the best of our ability to honor their memory. Professor Harvey Cushing said: "When to take great risks; when to withdraw in the face of unexpected difficulties; whether to force an attempted enucleation of a pathologically favorable tumor to its completion with the prospect of an operative fatality, or to abandon the procedure short of completeness with the certainty that after months or years even greater risks may have to be faced at a subsequent session-all these require surgical judgment which is a matter of long experience." It is up to us, therefore, to keep on the noble path that we have decided to undertake, to accumulate the surgical experience that these icons have shown us, the fruit of sacrifice and obstinacy. Our tribute goes to them; we will always remember their excellent work and their brilliant careers that will continue to enlighten all of us.

En Bloc Subtotal Temporal Bone Resection in a Case of Advanced Ear Cancer: 2-Dimensional Operative Video

Temporal bone cancer is extremely rare; thus, the optimal surgical strategy for advanced tumors, en bloc vs piecemeal resection, remain controversial. Some authors have favored piecemeal resection and reported comparable outcomes.1 Other authors recommend the use of en bloc subtotal temporal bone resection (STBR) for advanced tumors and reported better outcomes, although long-term cancer control remains uncertain.2 Because of the technical difficulty and the lack of demonstrative surgical videos, STBR has not been sufficiently distributed. This video demonstrates en bloc STBR in a stepwise manner with particular focus on the neurosurgeon's role and aims to improve its safety, feasibility, and distribution. This video conforms to the description of Osawa et al3 in the designations for each segment of the petrous ICA. A 67-yr-old man suffered from consistent otorrhea and underwent tympanoplasty at an outside hospital 1 yr earlier. Following a histopathological diagnosis of squamous cell carcinoma in the specimen, he underwent chemoradiotherapy (cisplatin + 70 Gy). However, a current imaging revealed a recurrent tumor and he was admitted to our hospital for radical resection. Computed tomography revealed a disrupted external auditory canal and magnetic resonance imaging indicated a carcinoma equivalent to Pittsburg stage T3. The patient underwent radical STBR without complications. His postoperative course was uneventful. At 2 yr postoperative, his modified Rankin scale score was 1, no recurrence was noted, and his facial nerve function was restored to House-Brackmann Grade IV. This video was reproduced with informed consent from the patient.

Early Report on the Impact of COVID-19 Outbreak in Neurosurgical Practice Among Members of the Latin American Federation of Neurosurgical Societies

BACKGROUND

The COVID-19 pandemic has caused severe economic consequences by local governmental measures to contain the outbreak. We provide insight on the impact that health care restriction has made on neurosurgical activity in Latin Iberoamerica.

METHODS

We performed an internet-based survey among presidents and members of the societies of the Latin American Federation of Neurosurgical Societies (FLANC). We blindly analyzed information regarding local conditions and their impact on neurosurgical praxis using SPSS software.

RESULTS

Information came from 21 countries. Sixteen society presidents reported having suspended regular activities and deferring local scheduled congresses, 14 reported mandatory isolation by government, and 4 instituted a telemedicine project. Four-hundred eighty-six colleagues, mean age 49 years, reported a mean 79% reduction in their neurosurgical praxis. Seventy-six percent of neurosurgeons have savings to self-support for 3-6 months if restrictions are long lasting.

CONCLUSIONS

Stopping activities among societies of the FLANC, together with a drop of 79% of neurosurgical praxis, adds to deficits in provider's protection equipment and increasing demand for attention in the health care systems, representing a huge financial risk to their sustainability. Neurosurgeons should be involved in local policies to protect health and economy. Telemedicine represents an excellent solution, avoiding another pandemic of severe diseases across all-specialties as nonessential care can turn essential if left untreated. Financial support and ethics code review is needed to battle this new disease, designated the occupational disease of the decade, that continues to scrag the health care system. Times of crisis are times of great opportunities for humanity to evolve.

Academic Productivity of Neurosurgeons Practicing in Joint Residency Advisory and Accreditation Committee Accredited Programs

BACKGROUND

Bibliometric indexes are often used to evaluate and compare neurosurgeons and departments, and they have been shown to correlate with academic rank and department reputation. We evaluated academic productivity of neurosurgeons practicing in departments accredited by the Joint Residency Advisory and Accreditation Committee and European Association of Neurological Surgeons.

METHODS

In a cross-sectional study, we calculated number of publications, citations, h-index, and m-quotient from PubMed and Web of Science databases for 285 neurosurgeons affiliated with 19 departments that are accredited or in progress of accreditation by the Joint residency Advisory and Accreditation Committee. Academic productivity was compared as a function of academic rank and research degree.

RESULTS

Median number of publications in PubMed and Web of Science indexed journals were 13 (range, 0-352) and 15 (range, 0-323), respectively. Median h-index was 4 (range, 0-41), and median m-quotient was 0.56 (range, 0-2.86). There was a significant variability between the studied departments in median number of publications and h-index (P = 0.001). Professors and associate professors had significantly higher bibliometric indexes than neurosurgeons without academic rank (all P values < 0.001). Department chairmen had higher bibliometric indexes than other faculty members (all P values < 0.001). Neurosurgeons holding a research degree authored more publications and had higher bibliometric indexes than faculty members not holding a research degree (P < 0.001).

CONCLUSIONS

This is the first study to evaluate academic productivity of neurosurgeons practicing in Europe and Turkey. Higher academic rank and advanced research degree were associated with greater academic productivity. Further studies exploring regional differences in academic productivity of European neurosurgeons are encouraged.

[The study of self-constructed brainstem fiber bundle by neurosurgeon through using 3D-Slicer software]

Objective: To explore the methods and appliaction value for self-constructing brainstem fiber bundles by neurosurgeon through 3D-Slicer software in neurosurgical preoperative planning. Methods: The DCIOM format imaging data of 31 patients with neurosurgical brainstem lesions were collected who admitted to Neurosurgery Department at the First Affiliated Hospital of Chongqing Medical University from June 2018 to May 2019 and imported into the 3D-Slicer software system. The neurosurgery specialists independently constructed the fiber bundles to generate two-dimensional Fraction Anisotropy maps, Directionally Encoded Color maps and three-dimensional fiber bundle tracing maps. Building a preopertive virtual pathological anatomical imaging system and understanding the three-dimensional pathological anatomical relationship between lesions and brain stem fiber bundles to develop an accurate surgical approach and simulate surgicalprocedures before surgery. Results: All cases were reconstructed by neurosurgeon, and the self-constructed 3D virtual images were used to develop the surgical plan. All the operations were successfully completed under the assistance of microsurgical techniques and neuroendoscopy while avoiding fiber bundles as much as possible, and the total or subtotal tumor was achieved without damage to the fiber bundle. After operation, the symptoms of new brainstem fiber bundle injury were mild. 31 patients were followed up 3 months after operation without obvious symptoms of brainstem fiber bundle injury, and 31 patients were followed up 6 months after operation without obvious symptoms of brainstem fiber bundle injury. Conclusions: Constructing brainstem fiber bundles by neurosurgeon can accurately and purposefully reconstruct the shape of brainstem fiber bundles, so that neurosurgeons can more accurately understand the three-dimensional pathological anatomical relationship between tumor and brain stem fiber bundles. In order to formulate the surgical plan in a more reasonable way, choose the optimal surgical approach, understand the location of the "relative safe area" , and be more confident to avoid damage to the brain stem fiber bundle while achieving subtotal or total resection of the tumor,also the nerve function of the patient is preserved as much as possible.

Physicians' awareness of gadolinium retention and MRI timing practices in the longitudinal management of pituitary tumors: a "Pituitary Society" survey

PURPOSE

In view of mounting attention related to possible brain retention of gadolinium-based contrast agents (GBCAs) in patients with normal renal function, our purpose was to detail results from a survey of pituitary experts to assess: 1) the timing interval and frequency of pituitary magnetic resonance imaging (MRI) following surgical and/or medical and/or radiation therapy of pituitary tumors, 2) awareness of the types of GBCAs used and their possible safety issues.

METHODS

The Pituitary Society Education Committee composed a survey with 12 multiple choice questions, 8 of which specifically addressed the time interval and frequency of MRI in the longitudinal management of pituitary tumors. The survey was distributed at two meetings; the International Pituitary Neurosurgeons Society conference in San Diego, CA, on February 18th, 2018, and the Pituitary Society Membership and Career Development Forum, Chicago, IL on March 18th, 2018.

RESULTS

There is consensus among pituitary endocrinologists and neurosurgeons that long-term repeated imaging is recommended in most pituitary tumors, although the precise strategy of timing varied depending on the specialist group and the specific clinical context of the adenoma. The data also suggest that International Pituitary Neurosurgeons Society neurosurgeons, as well as Pituitary Society neuroendocrinologists, are sometimes unaware of which contrast agents are used by their institution, and many are also unaware that evidence of long-term brain retention has been reported with the use of GBCAs in patients with normal function.

CONCLUSIONS

International pituitary endocrinologists and pituitary neurosurgeons experts suggest ongoing MRIs for the management of pituitary tumors; strategies vary based on clinical context, but also on individual experience and practice.

Geographic Analysis of Neurosurgery Workforce in Korea

Objective

In respect of the health and safety of the public, universal access to health care is an issue of the greatest importance. The geographic distribution of doctors is one of the important factors contributing to access to health care. The aim of this study is to assess the imbalances in the geographic distribution of neurosurgeons across Korea.

Methods

Population data was obtained from the National Statistical Office. We classified geographic groups into 7 metropolitan cities, 78 non-metropolitan cities, and 77 rural areas. The number of doctors and neurosurgeons per 100000 populations in each county unit was calculated using the total number of doctors and neurosurgeons at the country level from 2009 to 2015. The density levels of neurosurgeon and doctor were calculated and depicted in maps.

Results

Between 2009 and 2015, the number of neurosurgeons increased from 2002 to 2557, and the ratio of neurosurgeons per 100000 populations increased from 4.02 to 4.96. The number of neurosurgeons per 100000 populations was highest in metropolitan cities and lowest in rural areas from 2009 to 2015. A comparison of the geographic distribution of neurosurgeons in 2009 and 2015 showed an increase in the regional gap. The neurosurgeon density was affected by country unit characteristics (p=0.000).

Conclusion

Distribution of neurosurgeons throughout Korea is uneven. Neurosurgeons are being increasingly concentrated in a limited number of metropolitan cities. This phenomenon will need to be accounted when planning for a supply of neurosurgeons, allocation of resources and manpower, and the provision of regional neurosurgical services.

Professional burnout and its correlates in Lithuanian neurosurgeons

BACKGROUND

This study aimed to evaluate prevalence and severity of professional burnout in a sample of Lithuanian neurosurgeons and to analyze its personal, interpersonal, and organizational correlates.

METHOD

Thirty-one out of 79 (response rate 39 %) Lithuanian neurosurgeons participated in the study. Professional burnout was evaluated using the Maslach Burnout Inventory - General Survey. Participants also answered questions about professional stressors, sources of professional dissatisfaction, life-style factors, sickness absenteeism/presenteeism, and professional practice.

RESULTS

The majority of neurosurgeons were between 41 and 60 years of age (48 %), were married (97 %), had children (84 %). Most neurosurgeons had 20 or more years of professional experience (54.9 %), worked from 41 to 60 h per week (58 %), and performed up to 150 surgeries per year (77.4 %). Eight (26 %) neurosurgeons reported a high level of emotional exhaustion, five (16 %) reported high level of cynicism, and eight (26 %) reported low professional efficacy. Correlation analyses revealed that higher number of surgeries per year, more hours devoted to clinical work, opportunities for professional development, intellectual challenges at work, appreciation by the patients and prestige of the profession were related to lower level of burnout. Greater general workload, unpredictability of the work schedule, lack of necessary technical equipment, dissatisfaction with colleagues, and uncertainty about the future were related to a higher level of burnout.

CONCLUSIONS

Burnout was reported by one-quarter of neurosurgeons who chose to participate in the study. Personal, interpersonal, and organizational factors arising while fulfilling professional duties were important correlates of neurosurgeons' burnout. Due to the moderate response rate, our results should be interpreted with caution. Larger studies evaluating burnout among European neurosurgeons are needed.

Brain tumors in eloquent areas: A European multicenter survey of intraoperative mapping techniques, intraoperative seizures occurrence, and antiepileptic drug prophylaxis

Intraoperative mapping and monitoring techniques for eloquent area tumors are routinely used world wide. Very few data are available regarding mapping and monitoring methods and preferences, intraoperative seizures occurrence and perioperative antiepileptic drug management. A questionnaire was sent to 20 European centers with experience in intraoperative mapping or neurophysiological monitoring for the treatment of eloquent area tumors. Fifteen centers returned the completed questionnaires. Data was available on 2098 patients. 863 patients (41.1%) were operated on through awake surgery and intraoperative mapping, while 1235 patients (58.8%) received asleep surgery and intraoperative electrophysiological monitoring or mapping. There was great heterogeneity between centers with some totally AW oriented (up to 100%) and other almost totally ASL oriented (up to 92%) (31% SD). For awake surgery, 79.9% centers preferred an asleep-awake-asleep anesthesia protocol. Only 53.3% of the centers used ECoG or transcutaneous EEG. The incidence of intraoperative seizures varied significantly between centers, ranging from 2.5% to 54% (p < 0.001). It there appears to be a statistically significant link between the mastery of mapping technique and the risk of intraoperative seizures. Moreover, history of preoperative seizures can significantly increase the risk of intraoperative seizures (p < 0.001). Intraoperative seizures occurrence was similar in patients with or without perioperative drugs (12% vs. 12%, p = 0.2). This is the first European survey to assess intraoperative functional mapping and monitoring protocols and the management of peri- and intraoperative seizures. This data can help identify specific aspects that need to be investigated in prospective and controlled studies.

Variations in Practice Patterns among Neurosurgeons and Orthopaedic Surgeons in the Management of Spinal Disorders

Study Design

This is a case series.

Purpose

We wanted to identify variations in the practice patterns among neurosurgeons and orthopedic surgeons for the management of spinal disorders.

Overview of Literature

Spinal disorders are common in the clinical practice of both neurosurgeons and orthopedic surgeons. It has been observed that despite the availability of various guidelines, there is lack of consensus among surgeons about the management of various disorders.

Methods

A questionnaire was distributed, either directly or via e-mail, to the both the neurosurgeons and orthopedic surgeons who worked at 5 tertiary care centers within a single region of Korea. The surgeons were working either in private practice or in academic institutions. The details of the questionnaire included demographic details and the specialty (orthopedic/neurosurgeon). The surgeons were classified according to the level of experience as up to 5 years, 6-10 years and > 10 years. Questions were asked about the approach to lumbar discectomy (fragmentectomy or aggressive disc removal), using steroids for treating discitis, the fusion preference for spondylolisthesis, the role of an orthosis after fusion, the preferred surgical approach for spinal stenosis, the operative approach for spinal trauma (early within 72 hours or late > 72 hours) and the role of surgery in complete spinal cord injury. The data was analyzed using SPSS ver 16. p-values < 0.05 were considered to be significant.

Results

Of the 30 surgeons who completed the questionnaire, 20 were neurosurgeons and 10 were orthopedic surgeons. Statistically significant differences were observed for the management of spinal stenosis, spondylolisthesis, using an orthosis after fusion, the type of lumbar discectomy and the value of surgical intervention after complete spinal cord injury.

Conclusions

Our results suggest that there continues to exist a statistically significant lack of consensus among neurosurgeons and orthopedic spine surgeons when considering using an orthosis after fusion, the type of discectomy and the value of intervention after complete spinal injury.