Continuing Education for Global Neurosurgery Graduates: Visiting Surgeons, Skills Teaching, Bootcamps, and Twinning Programs.

Neurosurgeons require post-graduate training to deliver safe, effective, and evidence-based care; to continually improve and adapt their methods through assessing the effect of their care and patient outcomes; and to train the future neurosurgeons of tomorrow to surpass current standards of care. We describe methods used by global collaborations to address these training needs on a worldwide scale, their risks, and their perceived benefits.

Flexible support material maintains disc height and supports the formation of hydrated tissue engineered intervertebral discs in vivo.

Background: Mechanical augmentation upon implantation is essential for the long-term success of tissue-engineered intervertebral discs (TE-IVDs). Previous studies utilized stiffer materials to fabricate TE-IVD support structures. However, these materials undergo various failure modes in the mechanically challenging IVD microenvironment. FlexiFil (FPLA) is an elastomeric 3D printing filament that is amenable to the fabrication of support structures. However, no present study has evaluated the efficacy of a flexible support material to preserve disc height and support the formation of hydrated tissues in a large animal model. Methods: We leveraged results from our previously developed FE model of the minipig spine to design and test TE-IVD support cages comprised of FPLA and PLA. Specifically, we performed indentation to assess implant mechanical response and scanning electron microscopy to visualize microscale damage. We then implanted FPLA and PLA support cages for 6 weeks in the minipig cervical spine and monitored disc height via weekly x-rays. TE-IVDs cultured in FPLA were also implanted for 6 weeks with weekly x-rays and terminal T2 MRIs to quantify tissue hydration at study endpoint. Results: Results demonstrated that FPLA cages withstood nearly twice the deformation of PLA without detrimental changes in mechanical performance and minimal damage. In vivo, FPLA cages and stably implanted TE-IVDs restored native disc height and supported the formation of hydrated tissues in the minipig spine. Displaced TE-IVDs yielded disc heights that were superior to PLA or discectomy-treated levels. Conclusions: FPLA holds great promise as a flexible and bioresorbable material for enhancing the long-term success of TE-IVD implants.

The Use of Augmented Reality as an Educational Tool in Minimally Invasive Transforaminal Lumbar Interbody Fusion.

BACKGROUND AND OBJECTIVES: One of the major challenges in training neurosurgical and orthopedic residents the technique for minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is the lack of visualization of surgical landmarks (pedicle, pars, lamina). This is due to the limited access to the bony spine through a tubular retractor, in addition to a smaller working corridor or patient-specific factors such as bony overgrowth, disk space collapse, and listhesis. These factors increase the possibility for surgical error and prolonged surgery time. With augmented reality (AR), relevant surgical anatomy can be projected directly into the user's field of view through the microscope. The purpose of this study was to assess the utility, accuracy, efficiency, and precision of AR-guided MIS-TLIF and to determine its impact in spine surgery training. METHODS: At 2 centers, 12 neurosurgical residents performed a one-level MIS-TLIF on a high-fidelity lumbar spine simulation model with and without AR projection into the microscope. For the MIS-TLIF procedures with AR, surgical landmarks were highlighted in different colors on preoperative image data. These landmarks were visualized in the spinal navigation application on the navigation monitor and in the microscope to confirm the relevant anatomy. Postprocedural surveys (National Aeronautics and Space Administration Task Load Index) were given to the residents. RESULTS: Twelve residents were included in this trial. AR-guided procedures had a consistent impact on resident anatomical orientation and workload experience. Procedures performed without AR had a significantly higher mental demand (P = .003) than with AR. Residents reported to a significantly higher rate that it was harder work for them to accomplish their level of performance without AR (P = .019). CONCLUSION: AR can bring a meaningful value in MIS teaching and training to confirm relevant anatomy in situations where the surgeon will have less direct visual access. AR used in surgical simulation can also speed the learning curve.

Where are the women in spine surgery? A demographic study of the range of gender disparity in academic spine hospitals in the United States.

BACKGROUND CONTEXT: There is a paucity of women in the field of academic spine surgery. In 2022, 20% of orthopedic surgery residents and 24% of neurosurgery residents were women, the lowest and third lowest of all medical specialties respectively. There exists a significant discrepancy in the number of women employed as adult spine surgeons at academic hospitals. PURPOSE: To quantify the number of female attending spine surgeons at academic hospitals and identify institutions that based on faculty diversity are demonstrating inequity. STUDY DESIGN: Descriptive. METHODS: Demographic data was collected utilizing the 2023 to 2024 NASS Fellowship Directory in combination with publicly available information on faculty profiles from January 1, 2024 to January 30, 2024. Data collected included gender and training institutions (medical school, residency, and fellowship). Adult spine fellowship-trained orthopedic surgeons and neurosurgeons who perform adult spine surgery were included. RESULTS: There are 943 neurosurgical and orthopedic adult spine surgeons employed at 73 academic hospitals. The breakdown of orthopedic spine surgeons versus neurosurgeons is roughly equivalent, at 453 and 490, respectively. Among orthopedic spine surgeons, 19 out of 453 (4%) are female. Among neurosurgeons, 44 out of 490 (9%) are female. The number of female academic spine surgeons who are neurosurgeons is more than double that of orthopedic surgeons. Twelve out of the 19 (63%) female orthopedic spine surgeons, and 16 out of the 44 (36%) female neurosurgeons are employed at the program where they trained. Out of 45 larger academic spine hospitals with >10 faculty members, there were 15 without any female faculty. There is 1 academic hospital with ≥ 20 spine faculty, and zero women. CONCLUSION: The number of women pursuing academic spine careers continues to lag behind present day demographics of training programs. These continued trends should prompt both individuals and institutions to support progress in gender disparity research.

Clinical Capacity Building Through Partnerships: Boots on the Ground in Global Neurosurgery.

Global neurosurgery seeks to provide quality neurosurgical health care worldwide and faces challenges because of historical, socioeconomic, and political factors. To address the shortfall of essential neurosurgical procedures worldwide, dyads between established neurosurgical and developing centers have been established. Concerns have been raised about their effectiveness and ability to sustain capacity development. Successful partnerships involve multiple stakeholders, extended timelines, and twinning programs. This article outlines current initiatives and challenges within the neurosurgical community. This narrative review aims to provide a practical tool for colleagues embarking on clinical partnerships, the Engagements and assets, Capacity, Operative autonomy, Sustainability, and scalability (ECOSystem) of care. To create the ECOSystem of care in global neurosurgery, the authors had multiple online discussions regarding important points in the practical tool. All developed tiers were expanded based on logistics, clinical, and educational aspects. An online search was performed from August to November 2023 to highlight global neurosurgery partnerships and link them to tiers of the ECOSystem. The ECOSystem of care involves 5 tiers: Tiers 0 (foundation), 1 (essential), 2 (complexity), 3 (autonomy), and 4 (final). A nonexhaustive list of 16 neurosurgical partnerships was created and serves as a reference for using the ECOSystem. Personal experiences from the authors through their partnerships were also captured. We propose a tiered approach for capacity building that provides structured guidance for establishing neurosurgical partnerships with the ECOSystem of care. Clinical partnerships in global neurosurgery aim to build autonomy, enabling independent provision of quality healthcare services.

Is mechanism of injury associated with outcome in spinal trauma? An observational cohort study from Tanzania.

BACKGROUND: Traumatic spinal injury (TSI) is a disease of significant global health burden, particularly in low and middle-income countries where road traffic-related trauma is increasing. This study compared the demographics, injury patterns, and outcomes of TSI caused by road traffic accidents (RTAs) to non-traffic related TSI. METHODS: A retrospective analysis was conducted using a neurotrauma registry from the Muhimbili Orthopaedic Institute (MOI) in Tanzania, a national referral center for spinal injuries. Patient sociodemographic characteristics, injury level, and severity were compared across mechanisms of injury. Neurological improvement, neurological deterioration, and mortality were compared between those sustaining TSI through an RTA versus non-RTA, using univariable and multivariable analyses. RESULTS: A total of 626 patients were included, of which 302 (48%) were RTA-related. The median age was 34 years, and 532 (85%) were male. RTAs had a lower male preponderance compared to non-RTA causes (238/302, 79% vs. 294/324, 91%, p<0.001) and a higher proportion of cervical injuries (144/302, 48% vs. 122/324, 38%, p<0.001). No significant differences between RTA and non-RTA mechanisms were found in injury severity, time to admission, length of hospital stay, surgical intervention, neurological outcomes, or in-hospital mortality. Improved neurological outcomes were associated with incomplete injuries (AIS B-D), while higher mortality rates were linked to cervical injuries and complete (AIS A) injuries. CONCLUSION: Our study in urban Tanzania finds no significant differences in outcomes between spinal injuries from road traffic accidents (RTAs) and non-RTA causes, suggesting the need for equitable resource allocation in spine trauma programs. Highlighting the critical link between cervical injuries and increased mortality, our findings call for targeted interventions across all causes of traumatic spinal injuries (TSI). We advocate for a comprehensive trauma care system that merges efficient pre-hospital care, specialized treatment, and prevention measures, aiming to enhance outcomes and ensure equity in trauma care in low- and middle-income countries.

Urgent Call for International Support and Research Focus on Neurosurgery in Conflict-Affected Sudan.

Neurosurgical services and educational processes in Sudan have been severely disrupted by the ongoing armed conflict. The destruction of neurosurgical infrastructure and the continuous exodus of trained neurosurgeons from an already strained system have intensified the humanitarian crisis. The situation is further compounded by several factors, including attacks on medical professionals, partial suspension of neurosurgical training program, loss of communication tools, shortages of essential instruments, and disruptions in partnerships with regional and international neurosurgical associations. The re-establishment of international partnerships and the reconstruction of damaged neurosurgical infrastructure are advocated, coupled with the utilization of advanced research to address these critical issues. A staged recovery strategy is called for, and support from the global neurosurgical community is urged, highlighting the crucial role of academic platforms like "World Neurosurgery" in fostering global collaboration and disseminating research from conflict-affected regions.

Expandable cages that expand both height and lordosis provide improved immediate effect on sagittal alignment and short-term clinical outcomes following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF).

Background: Failure to restore lordotic alignment is not an uncommon problem following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF), even with expandable cages that increase disc height. This study aims to investigate the effect of the expandable cage that is specifically designed to expand both height and lordosis. We evaluated the outcomes of MIS TLIF in restoring immediate postoperative sagittal alignment by comparing two different types of expandable cages. One cage is designed to solely increase disc height (Group H), while the other can expand both height and lordosis (Group HL). Methods: Patients undergoing MIS TLIF using expandable cages were retrospectively reviewed, including 40 cases in Group H and 109 cases in Group HL. Visual analog scores of back and leg pain, and Oswestry disability index were collected. Disc height, disc angle, and sagittal alignment were measured. Complications were recorded, including early subsidence which was evaluated with computed tomography. Results: Clinical and radiographic outcomes significantly improved in both groups postoperatively. Group HL showed superior improvement in segmental lordosis (4.4°±3.5° vs. 2.1°±4.8°, P=0.01) and disc angle (6.3°±3.8 vs. 2.2°±4.3°, P<0.001) compared to Group H. Overall incidence of early subsidence was 23.3%, predominantly observed during initial cases as part of the learning curve, but decreased to 18% after completion of the first 20 cases. Conclusions: Expandable cages with a design specifically aimed at increasing lordotic angle can provide favorable outcomes and effectively improve immediate sagittal alignment following MIS TLIF, compared to conventional cages that only increase in height. However, regardless of the type of expandable cage used, it is crucial to avoid applying excessive force to achieve greater disc height or lordosis, as this may contribute to subsidence and a possible reduction in lordotic alignment restoration. Long-term results are needed to evaluate the clinical outcome, fusion rate, and maintenance of the sagittal alignment.

Presentation, Management, and Outcomes of Thoracic, Thoracolumbar, and Lumbar Spine Trauma in East Africa: A Cohort Study.

BACKGROUND: Trauma to the thoracic, thoracolumbar (TL), and lumbar spine is common and can cause disability and neurological deficits. Using a cohort of patients suffering from thoracic, TL, and lumbar spine trauma in a tertiary hospital in East Africa, the current study sought to: (1) describe demographics and operative treatment patterns, (2) assess neurologic outcomes, and (3) report predictors associated with undergoing surgery, neurologic improvement, and mortality. METHODS: A retrospective cohort study of patient records from September 2016 to December 2020 was conducted at a prominent East Africa referral center. The study collected data on demographics, injury, and operative characteristics. Surgical indications were assessed using the AO (Arbeitsgemeinschaft für Osteosynthesefragen) TL fracture classification system and neurological function. Logistic regression analysis identified predictors for operative treatment, neurologic improvement, and mortality. RESULTS: The study showed that 64.9% of the 257 TL spine trauma patients underwent surgery with a median postadmission day of 17.0. The mortality rate was 1.2%. Road traffic accidents caused 43.6% of the injuries. The most common fracture pattern was AO Type A fractures (78.6%). Laminectomy and posterolateral fusion were performed in 97.6% of the surgical cases. Patients without neurological deficits (OR: 0.27, 95% CI: 0.13-0.54, P < 0.001) and those with longer delays from injury to admission were less likely to have surgery (OR: 0.95, 95% CI: 0.92-0.99, P = 0.007). The neurologic improvement rate was 11.1%. Univariate analysis showed a significant association between surgery and neurologic improvement (OR: 3.83, 95% CI: 1.27-16.61, P < 0.001). However, this finding was lost in multivariate regression. CONCLUSIONS: This study highlights various themes surrounding the management of TL spine trauma in a low-resource environment, including lower surgery rates, delays from admission to surgery, safe surgery with low mortality, and the potential for surgery to lead to neurologic improvement. CLINICAL RELEVANCE: Despite challenges such as surgical delays and limited resources in East Africa, there is potential for surgical intervention to improve neurologic outcomes in thoracic, TL, and lumbar spine trauma patients.

Image-Guided Spine Surgery.

The realm of spine surgery is undergoing a transformative shift, thanks to the integration of image-guided navigation technology. This innovative system seamlessly blends real-time imaging data with precise location tracking. While the indispensable expertise of experienced spine surgeons remains irreplaceable, navigation systems bring a host of valuable advantages to the operating room. By offering a comprehensive view of the surgical anatomy, these systems empower surgeons to conduct procedures with accuracy, while minimizing radiation exposure for both patients and medical professionals. Moreover, image-guided navigation paves the way for integration of other state-of-the-art technologies, such as augmented reality and robotics. These innovations promise to further revolutionize the field, providing greater precision and expanding the horizons of what is possible in the world of spinal procedures. This article explores the evolution, classification, and impact of image-guided spine surgery, underscoring its pivotal role in enhancing efficacy and safety while setting the stage for the incorporation of future technological advancements.

Reliability of a Novel Classification System for Thoracic Disc Herniations.

STUDY DESIGN: This is a cross-sectional survey. OBJECTIVE: The aim was to assess the reliability of a proposed novel classification system for thoracic disc herniations (TDHs). SUMMARY OF BACKGROUND DATA: TDHs are complex entities varying substantially in many factors, including size, location, and calcification. To date, no comprehensive system exists to categorize these lesions. METHODS: Our proposed system classifies 5 types of TDHs using anatomic and clinical characteristics, with subtypes for calcification. Type 0 herniations are small (≤40% of spinal canal) TDHs without significant spinal cord or nerve root effacement; type 1 are small and paracentral; type 2 are small and central; type 3 are giant (>40% of spinal canal) and paracentral; and type 4 are giant and central. Patients with types 1 to 4 TDHs have correlative clinical and radiographic evidence of spinal cord compression. Twenty-one US spine surgeons with substantial TDH experience rated 10 illustrative cases to determine the system's reliability. Interobserver and intraobserver reliability were determined using the Fleiss kappa coefficient. Surgeons were also surveyed to obtain consensus on surgical approaches for the various TDH types. RESULTS: High agreement was found for the classification system, with 80% (range 62% to 95%) overall agreement and high interrater and intrarater reliability (kappa 0.604 [moderate to substantial agreement] and kappa 0.630 [substantial agreement], respectively). All surgeons reported nonoperative management of type 0 TDHs. For type 1 TDHs, most respondents (71%) preferred posterior approaches. For type 2 TDHs, responses were roughly equivalent for anterolateral and posterior options. For types 3 and 4 TDHs, most respondents (72% and 68%, respectively) preferred anterolateral approaches. CONCLUSIONS: This novel classification system can be used to reliably categorize TDHs, standardize description, and potentially guide the selection of surgical approach. Validation of this system with regard to treatment and clinical outcomes represents a line of future study.

Finite element modeling to predict the influence of anatomic variation and implant placement on performance of biological intervertebral disc implants.

Background: Tissue-engineered intervertebral disc (TE-IVD) constructs are an attractive therapy for treating degenerative disc disease and have previously been investigated in vivo in both large and small animal models. The mechanical environment of the spine is notably challenging, in part due to its complex anatomy, and implants may require additional mechanical support to avoid failure in the early stages of implantation. As such, the design of suitable support implants requires rigorous validation. Methods: We created a FE model to simulate the behavior of the IVD cages under compression specific to the anatomy of the porcine cervical spine, validated the FE model using an animal model, and predicted the effects of implant location and vertebral angle of the motion segment on implant behavior. Specifically, we tested anatomical positioning of the superior vertebra and placement of the implant. We analyzed corresponding stress and strain distributions. Results: Results demonstrated that the anatomical geometry of the porcine cervical spine led to concentrated stress and strain on the posterior side of the cage. This stress concentration was associated with the location of failure of the cages reported in vivo, despite superior mechanical properties of the implant. Furthermore, placement of the cage was found to have profound effects on migration, while the angle of the superior vertebra affected stress concentration of the cage. Conclusions: This model can be utilized both to inform surgical procedures and provide insight on future cage designs and can be adopted to models without the use of in vivo animal models.

Ten-step minimally invasive slalom unilateral laminotomy for bilateral decompression (sULBD) with navigation.

BACKGROUND: Unilateral laminotomy for bilateral decompression (ULBD) is a MIS surgical technique that offers safe and effective decompression of lumbar spinal stenosis (LSS) with a long-term resolution of symptoms. Advantages over conventional open laminectomy include reduced expected blood loss, muscle damage, mechanical instability, and less postoperative pain. The slalom technique combined with navigation is used in multi-segmental LSS to improve the workflow and effectiveness of the procedure. METHODS: We outline ten technical steps to achieve a slalom unilateral laminotomy for bilateral decompression (sULBD) with navigation. In a retrospective case series, we included patients with multi-segmental LSS operated in our institution using the sULBD between 2020 and 2022. The primary outcome was a reduction in pain measured by Visual Analogue Scale (VAS) for back pain and leg pain and Oswestry Disability Index (ODI). RESULTS: In our case series (N = 7), all patients reported resolution of initial symptoms on an average follow-up of 20.71 ± 9 months. The average operative time and length of hospital stay were 196.14 min and 1.67 days, respectively. On average, VAS (back pain) was 4.71 pre-operatively and 1.50 on long-term follow-up of an average of 19.05 months. VAS (leg pain) decreased from 4.33 to 1.21. ODI was reported as 33% pre-operatively and 12% on long-term follow-up. CONCLUSION: The sULBD with navigation is a safe and effective MIS surgical procedure and achieves the resolution of symptoms in patients presenting with multi-segmental LSS. Herein, we demonstrate the ten key steps required to perform the sULBD technique. Compared to the standard sULBD technique, the incorporation of navigation provides anatomic localization without exposure to radiation to staff for a higher safety profile along with a fast and efficient workflow.

Evaluating the Feasibility and Outcomes of a Scoliosis Surgical Camp in a Resource-Limited Setting in Sub-Saharan Africa.

BACKGROUND: In sub-Saharan Africa, the estimated prevalence of scoliosis ranges from 3.3% to 5.5%. The management of these deformities is restricted due to lack of infrastructure and access to deformity spine surgeons. Utilizing surgical camps has been demonstrated to be efficient in transferring skills to low-resource environments; however, this has not been documented concerning deformity surgery. METHODS: We conducted a cross-sectional study. The scoliosis camp was held at a major referral spine center in East Africa. We documented information about the organization of the course. We also collected clinical and demographic patient data. Finally, we assessed the knowledge and confidence among surgeon participants on the management scoliosis. RESULTS: The camp lasted 5 days and consisted of lectures and case discussions, followed by casting and surgical sessions. Five patients were operated during the camp. All the patients in the study were diagnosed with AIS, except one with a congenital deformity. The primary curve in the spine was in the thoracic region for all patients. Six months postoperative Scoliosis Research Society-22R Scoring System (SRS-22R) score ranged from 3.3-4.5/5. 87.5% of the participants found the course content satisfactory. CONCLUSIONS: To the best of our knowledge, this is the first time an African scoliosis camp has been established. The study highlights the difficulty of conducting such a course and illustrates the feasibility of executing these complex surgeries in a resource-limited environment.

Regulation, approval, and access of spinal implants in low-middle-income countries: a narrative review and case study.

INTRODUCTION: Spinal implants play a vital role in healthcare delivery, and regulations are necessary to ensure their quality, approval, access, and use. In this article, we examine the current state of regulation and approval procedures for medical devices in low- and middle-income countries (LMICs), emphasizing the situation in Tanzania. AREAS COVERED: We conducted a systematic literature search and interviewed a local spine implant representative to investigate the approval, availability, and access of surgical and spinal implants in LMICs, particularly in Africa. Out of the 18 included articles, six referred to African regulations, with no mention of spinal implants. Our analysis revealed that LMICs face challenges in accessing implants due to affordability, poor supply chain, and lack of expertise for their application. However, surgeons have found alternative solutions, such as using lower-cost implants from Turkish manufacturers. The Tanzania Medical Devices and Drugs Authority oversees the local regulatory and approval process for implants. EXPERT OPINION: Regulation and accessibility of spinal implants in LMICs, particularly in Africa, are limited and negatively impact patient care and best medical practice. Potential solutions include capacity building within and collaboration among regulatory organizations to improve regulatory processes and allocating financial resources to qualitative and quantitative implant access.

Feasibility of High-Fidelity Simulator Models for Minimally Invasive Spine Surgery in a Resource-Limited Setting: Experience From East Africa.

BACKGROUND: Spine surgery is a rapidly evolving specialty with a continuous need to learn new skills. In resource-limited settings such as Africa, the need for training is greater. The use of simulation-based training is important in different stages of skill acquisition, especially for high-stake procedures such as spine surgery. Among the available methods of simulation, the use of synthetic models has gained popularity among trainers. METHOD: Twenty participants of a neurosurgery training course, most of whom (65%) were neurosurgery residents and fellows, were recruited. They had hands-on training sessions using a high-fidelity lumbar degenerative spine simulation model and hands-on theater experience. After this, they completed a survey to compare their experience and assess the effectiveness of the lumbar spine model in stimulating real patient and surgery experiences. RESULTS: The participants were from four African countries, and the majority were neurosurgery residents. There were varying levels of experience among the participants in minimally invasive spine surgery, with the majority either having no experience or having only observed the procedure. All the participants said that the high-fidelity lumbar spine model effectively simulated real minimally invasive spine setup and real bone haptics and was effective in learning new techniques. Most of the participants agreed that the model effectively simulated real dura and nerve roots (95%), real muscle (90%), real bleeding from bones and muscles (95%), and real cerbrospinal fluid in the subarachnoid space. Among them, 95% agreed that the model is effective in lumbar minimally invasive spine training in resource-limited settings. CONCLUSION: With the development of new and better surgical techniques, the use of high-fidelity models provides a good opportunity for learning and training, especially in resource-poor settings where there is a paucity of training facilities and personnel.

Neurosurgical Education in Tanzania: The Dar es Salaam Global Neurosurgery Course.

BACKGROUND: Postgraduate neurosurgical training is essential to develop a neurosurgical workforce with the skills and knowledge to address patient needs for neurosurgical care. In Tanzania, the number of neurosurgeons and neurosurgical services offered have expanded in the past 40 years. Training opportunities within the country, however, are not sufficient to meet the needs of residents, specialists, and nurses in neurosurgery, forcing many to train outside the country incurring associated costs and burdens. We report on the Dar es Salaam Global Neurosurgery Course, which aims to provide local training to neurosurgical health care providers in Tanzania and surrounding countries. METHODS: We report the experience of the Global Neurosurgery Course held in March 2023 in Dar es Salaam, Tanzania. We describe the funding, planning, organization, and teaching methods along with participant and faculty feedback. RESULTS: The course trained 121 participants with 63 faculty-42 from Tanzania and 21 international faculty. Training methods included lectures, hands-on surgical teaching, webinars, case discussions, surgical simulation, virtual reality, and bedside teaching. Although there were challenges with equipment and Internet connectivity, participant feedback was positive, with overall improvement in knowledge reported in all topics taught during the course. CONCLUSIONS: International collaboration can be successful in delivering topic-specific training that aims to address the everyday needs of surgeons in their local setting. Suggestions for future courses include increasing training on allied topics to neurosurgery and neurosurgical subspecialty topics, reflecting the growth in neurosurgical capacity and services offered in Tanzania.

Artificial Intelligence in Neurosurgery: A State-of-the-Art Review from Past to Future.

In recent years, there has been a significant surge in discussions surrounding artificial intelligence (AI), along with a corresponding increase in its practical applications in various facets of everyday life, including the medical industry. Notably, even in the highly specialized realm of neurosurgery, AI has been utilized for differential diagnosis, pre-operative evaluation, and improving surgical precision. Many of these applications have begun to mitigate risks of intraoperative and postoperative complications and post-operative care. This article aims to present an overview of the principal published papers on the significant themes of tumor, spine, epilepsy, and vascular issues, wherein AI has been applied to assess its potential applications within neurosurgery. The method involved identifying high-cited seminal papers using PubMed and Google Scholar, conducting a comprehensive review of various study types, and summarizing machine learning applications to enhance understanding among clinicians for future utilization. Recent studies demonstrate that machine learning (ML) holds significant potential in neuro-oncological care, spine surgery, epilepsy management, and other neurosurgical applications. ML techniques have proven effective in tumor identification, surgical outcomes prediction, seizure outcome prediction, aneurysm prediction, and more, highlighting its broad impact and potential in improving patient management and outcomes in neurosurgery. This review will encompass the current state of research, as well as predictions for the future of AI within neurosurgery.