Association of area deprivation index (ADI) with demographics and postoperative outcomes in pediatric brain tumor patients.

PURPOSE: Although social determinants of health (SDOH) have been associated with adverse surgical outcomes, cumulative effects of multiple SDOH have never been studied. The area deprivation index (ADI) assesses cumulative impact of SDOH factors on outcomes. We analyzed the relationship between ADI percentile and postoperative outcomes in pediatric patients diagnosed with brain tumors. METHODS: A retrospective, observational study was conducted on our consecutive series of pediatric brain tumor patients presenting between January 1, 1999, and May 31, 2022. Demographics and outcomes were collected, identifying SDOH factors influencing outcomes found in the literature. ADI percentiles were identified based on patient addresses, and patients were stratified into more (ADI 0-72%) and less (ADI 73-100%) disadvantaged cohorts. Univariate and multivariate logistic regression analyses were completed for demographics and outcomes. RESULTS: A total of 272 patients were included. Demographics occurring frequently in the more disadvantaged group were Black race (13.1% vs. 2.8%; P = .003), public insurance (51.5% vs. 27.5%; P < .001), lower median household income ($64,689 ± $19,254 vs. $46,976 ± $13,751; P < .001), and higher WHO grade lesions (15[11.5%] grade III and 8[6.2%] grade IV vs. 8[5.6%] grade III and 5[3.5%] grade IV; P = .11). The more disadvantaged group required adjunctive chemotherapy (25.4% vs. 12.05%; P = .007) or radiation therapy (23.9% vs. 12.7%; P = .03) more frequently and had significantly greater odds of needing adjunctive chemotherapy (odds ratio [OR], 1.11; confidence interval [CI], 1.01-1.22; P = .03) in a multivariate model, which also identified higher WHO tumor grades at presentation (OR, 1.20; CI, 1.14-1.27; P < .001). CONCLUSION: These findings are promising for use of ADI to represent potential SDOH disadvantages that pediatric patients may face throughout treatment. Future studies should pursue large multicenter collaborations to validate these findings.

Contemporary Surgical Management of Craniofacial Fibrous Dysplasia Using Computer-Assisted Surgery and Intraoperative Navigation.

Craniofacial fibrous dysplasia (CFD) is a rare developmental disease of bone, which typically presents as a painless, expansile mass causing deformity of the craniofacial skeleton. In rare circumstances, compression of neurovascular structures may arise, causing symptoms such as pain, visual impairment, and hearing loss. Traditionally, CFD debulking has been performed with "freehand" techniques using preoperative imaging and anthropometric norms to determine the ideal amount of tissue removal. The advent of computer-assisted surgery, computer-aided design, and computer-aided manufacturing (CAD/CAM) has revolutionized the management of CFD. Surgeons can now fabricate patient-specific osteotomy/ostectomy guides, allowing for increased accuracy in bone removal and improved cosmetic outcomes. This series of 3 cases describe our institution's technique using patient-specific ostectomy "depth guides", which allow for maximum removal of fibro-osseous tissue while sparing deep and adjacent critical structures. These techniques can be widely applied to the craniofacial skeleton to assist in the surgical management of CFD.

Which Sport Is More Dangerous: Ice Hockey or Field Hockey? A Review of the Head and Neck Injuries Associated With the Two Sports.

PURPOSE: Ice hockey and field hockey are contact sports with the potential for injury, especially to the head and neck regions. The purpose of this study is to estimate and compare hospital admission (injury severity) between ice hockey and field hockey of those who presented to the emergency department with head and neck injuries. METHODS: The investigators designed and implemented a 20-year retrospective cohort study using the National Electronic Injury Surveillance System database. We included data related to ice hockey and field hockey injuries from January 2000 to December 2019 in this study. The primary predictor variable was sport played (ice hockey vs field hockey). Secondary predictor variables and covariates were derived from patient and injury characteristics. The primary outcome variable was hospital admission. Logistic regression was used to determine independent risk factors for the outcome variable. RESULTS: Our final sample was composed of 5,472 patients: 4,472 patients suffered head and neck injuries from ice hockey while the remaining 1,000 patients suffered head and neck injuries from field hockey. Players less than 18 years old were associated with 2.07-fold odds of admission (P < .01). Injury to the head (odds ratio [OR] = 14.339; 95% confidence interval [CI], 2.0 to 105.1; P < .01) and neck (OR = 89.260; 95% CI, 11.2 to 712.6; P < .01) were independently associated with an increased odds of admission. Relative to contusions/abrasions, players who suffered a concussion (OR = 141.637; 95% CI, 11.5 to 1,741.5; P < .01), fracture (OR = 155.434; 95% CI, 17.0 to 1,419.2; P < .01), internal organ injury (OR = 186.450; 95% CI, 15.5 to 2,236.8; P < .01), or hematoma (OR = 23.046; 95% CI, 1.2 to 442.5; P < .05) were all independently associated with an increased odds of admission. Ice hockey was not an independent risk factor for admission relative to field hockey. CONCLUSIONS: The findings of this study suggest that ice hockey was more associated with injuries to the head and neck as well as with concussions and internal organ injury compared to field hockey. However, ice hockey was not associated with increased risk of hospitalization relative to field hockey.

Dexmedetomidine for acute baclofen withdrawal.

BACKGROUND: Intrathecal baclofen is widely accepted as a treatment option for severe spasticity through its γ-Aminobutyric acid-B (GABAB ) agonist properties. Abrupt cessation can lead to severe and life-threatening withdrawal characterized by altered mental status, autonomic dysreflexia, rigidity, and seizures. This symptomatic presentation is similar to alcohol withdrawal, which is mediated by modification of GABAA expression. Use of the α2-adrenergic agonist dexmedetomidine for the treatment of ethanol withdrawal has been widely reported, raising the question of its potential role in baclofen withdrawal. We present a case of the successful treatment of acute severe baclofen withdrawal with a dexmedetomidine infusion. METHODS: A 15-year-old patient with spastic quadriparesis and cerebral palsy underwent unexpected removal of his baclofen pump due to an infection that was encountered during a planned pump revision. Following removal, he was placed on high dose enteral baclofen every 6 h. Despite further benzodiazepine supplementation, he had progressive hemodynamic instability, severe rebound spasticity, and intermittent spontaneous clonus consistent with baclofen withdrawal. A dexmedetomidine infusion was titrated to a peak dose of 16 mcg per hour with successful treatment of withdrawal symptoms. RESULTS: The patient became normotensive without tachycardia. Tone and agitation improved. CONCLUSION: Dexmedetomidine is to our knowledge a previously unreported option for treatment of acute severe baclofen withdrawal. We report a case of safe and efficacious use in a patient with spastic quadriparesis on chronic intrathecal baclofen. Scientifically rigorous comparison with other options remains to be performed.

An Analysis of the Relationship Between Female Faculty and Female Resident Representation in Neurosurgery Residency Programs.

BACKGROUND: Promoting minorities within medical specialties has been postulated to be crucial to patient care and recruitment of diverse candidates. This concept has been suspected but not formally studied in the minority of women faculty and trainees in neurosurgery. We aimed to quantitatively investigate the postulated correlation relative to female representation in neurosurgery. METHODS: Data obtained from accredited neurosurgery residency programs were reviewed. Data describing the percentage of female residents and 6 demographic and 14 program-specific variables were collected. All program websites were reviewed to assess percentages of female faculty and visible commitment to diversity in applicants, evident through communicated policies, statements, or initiatives. Included programs were defined as "low" or "high" percentage of female residents or faculty relative to the grouped median value for both categories; groups were assessed for significant differences. Percentages of female faculty and residents and program-communicated diversity initiatives were investigated for significant correlation. RESULTS: Female faculty and diversity data were available at 117 program sites; 81 programs reported female resident percentages. Analysis revealed a significant positive correlation between female faculty and female resident percentages. Programs with higher female resident percentages had higher levels of diversity in terms of race and ethnicity. No significant correlation was found between the percentage of female faculty or residents and a communicated diversity initiative. CONCLUSION: This study of current female representation in neurosurgery revealed a previously undocumented positive correlation between percentages of female faculty and female trainees. These data suggest a modifiable barrier to female entry into neurosurgical residency programs.

An online calculator using machine learning for predicting survival in pediatric patients with medulloblastoma.

OBJECTIVE: Medulloblastoma is the most common malignant intracranial tumor affecting the pediatric population. Despite advancements in multimodal treatment over the past 2 decades yielding a 5-year survival rate > 75%, children who survive often have substantial neurological and cognitive sequelae. The authors aimed to identify risk factors and develop a clinically friendly online calculator for prognostic estimation in pediatric patients with medulloblastoma. METHODS: Pediatric patients with a histopathologically confirmed medulloblastoma were extracted from the Surveillance, Epidemiology, and End Results database (2000-2018) and split into training and validation cohorts in an 80:20 ratio. The Cox proportional hazards model was used to identify the univariate and multivariate survival predictors. Subsequently, a calculator with those factors was developed to predict 2-, 5-, and 10-year overall survival as well as median survival months for pediatric patients with medulloblastoma. The performance of the calculator was determined by discrimination and calibration. RESULTS: One thousand seven hundred fifty-nine pediatric patients with medulloblastoma met the prespecified inclusion criteria. Age, sex, race, ethnicity, median household income, county attribute, laterality, anatomical location, tumor grade, tumor size, surgery status, radiotherapy, and chemotherapy were variables included in the calculator (https://spine.shinyapps.io/Peds_medullo/). The concordance index was 0.769 in the training cohort and 0.755 in the validation cohort, denoting clinically useful predictive accuracy. Good agreement between the predicted and observed outcomes was demonstrated by the calibration plots. CONCLUSIONS: An easy-to-use prognostic calculator for a large cohort of pediatric patients with medulloblastoma was established. Future efforts should focus on improving granularity of population-based registries and externally validating the proposed calculator.

Accuracy of Surgical Outcome Using Computer-Aided Surgical Simulation in Fronto-Orbital Advancement for Craniosynostosis: A Pilot Study.

BACKGROUND AND OBJECTIVE: Computer-aided surgical simulation (CASS) can be used to virtually plan ideal outcomes of craniosynostosis surgery. Our purpose was to create a workflow analyzing the accuracy of surgical outcomes relative to virtually planned fronto-orbital advancement (FOA). METHODS: Patients who underwent FOA using CASS between October 1, 2017, and February 28, 2022, at our center and had postoperative computed tomography within 6 months of surgery were included. Virtual 3-dimensional (3D) models were created and coregistered using each patient's preoperative and postoperative computed tomography data. Three points on each bony segment were used to define the object in 3D space. Each planned bony segment was manipulated to match the actual postoperative outcome. The change in position of the 3D object was measured in translational (X, Y, Z) and rotational (roll, pitch, yaw) aspects to represent differences between planned and actual postoperative positions. The difference in the translational position of several bony landmarks was also recorded. Wilcoxon signed-rank tests were performed to measure significance of these differences from the ideal value of 0, which would indicate no difference between preoperative plan and postoperative outcome. RESULTS: Data for 63 bony segments were analyzed from 8 patients who met the inclusion criteria. Median differences between planned and actual outcomes of the segment groups ranged from -0.3 to -1.3 mm in the X plane; 1.4 to 5.6 mm in the Y plane; 0.9 to 2.7 mm in the Z plane; -1.2° to -4.5° in pitch; -0.1° to 1.0° in roll; and -2.8° to 1.0° in yaw. No significant difference from 0 was found in 21 of 24 segment region/side combinations. Translational differences of bony landmarks ranged from -2.7 to 3.6 mm. CONCLUSION: A high degree of accuracy was observed relative to the CASS plan. Virtual analysis of surgical accuracy in FOA using CASS was feasible.

Fronto-Orbital Advancement Using Computer-Aided Surgical Simulation: 2-Dimensional Operative Video.

Craniosynostosis is a developmental anomaly resulting from the premature fusion of cranial sutures, with an estimated incidence of 1 per 2000 to 1 per 2500 births.1 Surgical options for correction include open calvarial vault reconstruction, and more recently, endoscopic-assisted repairs that have been introduced to mitigate blood loss and hospital stay,2 although these remain understudied. In this operative video (Video), the authors present the case of an 11-month-old girl with right-sided coronal craniosynostosis that was treated with coronal cranial vault reconstruction with fronto-orbital advancement using computer-aided surgical simulation (KLS Martin Group), which has been studied previously with acceptable results when comparing the preoperative plan to the postoperative outcome.3 The patient was seen in follow-up at 1 month and 6 months and remained neurologically intact, continuing to meet all her developmental milestones appropriately. The patient's guardians consented to performance of the procedure and publication of the images. Institutional review board approval was deemed unnecessary. The participants and any identifiable individuals consented to publication of his/her images.

Social Determinants of Health and Associations With Outcomes in Pediatric Patients With Brain Tumors.

BACKGROUND AND OBJECTIVES: Social determinants of health (SDOH) are nonmedical factors that affect health outcomes. Limited investigation has been completed on the potential association of these factors to adverse outcomes in pediatric populations. In this study, the authors aimed to analyze the effects of SDOH disparities and their relationship with outcomes after brain tumor resection or biopsy in children. METHODS: The authors retrospectively reviewed the records of their center's pediatric patients with brain tumor. Black race, public insurance, median household income, and distance to hospital were the investigated SDOH factors. Univariate analysis was completed between number of SDOH factors and patient demographics. Multivariate linear regression models were created to identify coassociated determinants and outcomes. RESULTS: A total of 272 patients were identified and included in the final analysis. Among these patients, 81 (29.8%) had no SDOH disparities, 103 (37.9%) had 1, 71 (26.1%) had 2, and 17 (6.2%) had 3. An increased number of SDOH disparities was associated with increased percentage of missed appointments ( P = .002) and emergency room visits ( P = .004). Univariate analysis demonstrated increased missed appointments ( P = .01), number of postoperative imaging ( P = .005), and number of emergency room visits ( P = .003). In multivariate analysis, decreased median household income was independently associated with increased length of hospital stay ( P = .02). CONCLUSION: The SDOH disparities are prevalent and impactful in this vulnerable population. This study demonstrates the need for a shift in research focus toward identifying the full extent of the impact of these factors on postoperative outcomes in pediatric patients with brain tumor.

The Most Dangerous Game: A Review of Head and Neck Injuries in American Football and Rugby.

Study Design: The investigators designed and implemented a 20-year cross-sectional study using the National Electronic Injury Surveillance System database. Objective: The purpose of this study is to estimate and compare hospital admission (danger) rates between rugby and football of those who presented to the emergency department with head and neck injuries after playing these sports. Methods: The primary predictor variable was sport played. The primary outcome variable was danger, measured by hospital admission rates. Results: Over the past 20 years, there has been a trend of decreasing incidence of injuries presenting to the emergency department in both sports. There was no difference in the rate of hospital admission when comparing football and rugby (OR, 1.2; P = .1). Male gender was associated with an increased risk of admission. Other variables associated with hospital admission included white racial group, injury taking place in the fall, being either young (15-24 years old) or senior (65 years of age and over), and being injured at school or at a sport/recreational facility. Conclusions: There is no difference in danger as measured by admission rates between American football and rugby. There exists, however, several variables that are associated with admission when sustaining injury to the head and neck, when playing these two sports.

Head and neck angiography in the pediatric population: single-center experience with indications, safety, feasibility, and technical differences among infants, childhood, and adolescents.

OBJECTIVE: Pediatric patients are candidates for head and neck endovascular procedures less frequently than adults. Data on utilization, feasibility, safety, and technical details of head and neck angiography in the pediatric population are scarce. METHODS: The authors performed a retrospective review of their center's endovascular database to identify all patients ≤ 18 years of age who underwent diagnostic or interventional catheter-based angiography of the head and neck. Procedure-related variables for identified patients were compared across infancy (birth to 2 years), childhood (> 2-11 years), and adolescence (> 11-18 years). RESULTS: One hundred twenty-one pediatric patients who underwent 274 angiogram procedures were included in this study. Of these angiograms, 197 were diagnostic and 118 were interventional (including 41 of the diagnostic angiogram procedures that were performed concurrently with the intervention). The most common indications for diagnostic angiograms were suspected vascular malformations in 52 cases (26.4%) and aneurysms in 23 (11.7%). The rate of positive findings on diagnostic angiograms ranged from 27.3% to 80% according to the indication. Access site-related complications were observed after 2 punctures (0.7%). Procedure-related complications occurred in 3 patients (1.1%). In adolescents, the rates of general anesthesia use and sheathless access were significantly lower (each p < 0.001), and the rates of radial artery access (p < 0.001); 5-French (5F) (p = 0.01), 6F (p < 0.001), and 8F (p = 0.03) access; and closure device usage (p < 0.001) were significantly higher. In infants, the rates of ultrasound guidance, 4F access, and failure of the primary puncture site were significantly higher (each p < 0.001). CONCLUSIONS: Head and neck angiograms in the pediatric population were feasible and safe in the authors' overall experience. Technical differences were observed across the infant, childhood, and adolescent groups, but safe outcomes were similar throughout these age ranges.

Management of Sagittal and Lambdoid Craniosynostosis: Open Cranial Vault Expansion and Remodeling.

The prevalence of sagittal and lambdoid suture craniosynostosis differs considerably, as they are notably the most and least prevalent sutures involved in isolated suture craniosynostosis, respectively. The goals of reconstructing the cranial vault in both entities is the same: to release the fused suture, expand cranial volume, restore normal head shape and morphology, and allow for normal growth of the cranial vault. With regards to sagittal suture synostosis, opinions vary on whether reconstruction should focus on either the anterior or poster cranial vault. In contrast, the poster cranial vault is always targeted in lambdoid suture craniosynostosis.

Ventral Intrameningeal Cyst Treatment and Management: Technical Note.

BACKGROUND: Intrameningeal cysts are rare lesions without definitive etiologies that can involve the dura or arachnoid mater. Spinal arachnoid cysts have been described, and several different etiologies have been hypothesized. This includes one-way valve mechanisms, traumatic herniation of arachnoid through the dura, and abnormal arachnoid membrane proliferation. To the authors' knowledge, no such descriptions exist regarding purely dural-based cystic lesions; however, the authors hypothesize similar mechanisms may be involved. Most notably, a traumatic injury to the dura leading to a one-way valve mechanism may allow for egress of cerebrospinal fluid between the dural layers, splitting them open. This progressive enlargement can lead to displacement of neural elements and subsequent neurological compromise. METHODS: We describe a 17-year-old girl who presented with progressive neck and back pain, left upper-extremity numbness, bilateral lower-extremity weakness, paresthesias, and numbness without obvious etiology despite an extensive neurologic investigation. She had undergone conservative management options including multiple medications, physical and chiropractic therapy, and epidural steroid injections. Computed tomography myelography revealed a cerebrospinal fluid leak into the lumbar epidural space for which surgical exploration was performed. Despite utilizing fluoroscopy and intrathecal fluorescein, no leak source was identified. Fluid collection was found contained within the dural layers rather than the epidural space. RESULTS: An intracystic blood patch was performed with near-complete resolution of the lesion by 6-week follow-up and near-complete return of neurologic function. CONCLUSIONS: Ventral panspinal cysts are an exceedingly rare cause of radiculopathy and myelopathy that can be resolved by an intracystic blood patch.

Impaired wound healing following cranial vault reconstruction in a patient with an atypical phenotype of Marfan syndrome: A case report.

Background: Marfan syndrome (MFS) is an autosomal dominant disorder of the connective tissues caused by mutations in the FBN1 gene which can result in widespread systemic involvement. Loeys-Dietz syndrome (LDS) is a related autosomal dominant disorder of connective tissue with widespread systemic involvement which has phenotypic overlap with MFS. LDS is caused by heterozygous pathogenic variants in six different genes, the most common of which involve transforming growth factor beta-receptor 1 or 2. While LDS is commonly associated with craniofacial manifestations, MFS is not typically characterized by craniosynostosis. Case Description: We present a 7-month-old female patient with MFS and metopic craniosynostosis with an unusual clinical presentation who underwent cranial vault reconstruction with fronto-orbital advancement and anterior cranial vault remodeling. Her course was complicated by impaired wound healing after surgery, requiring return to the operating room. Conclusion: Phenotypic overlap between genetic disorders can confound clinical diagnosis as illustrated in this case. Genetic testing can be highly valuable in the diagnosis of clinically variable disorders. Patients with MFS who undergo cranial surgery may be at increased risk for wound healing complications.

Moral Distress and Moral Injury Among Attending Neurosurgeons: A National Survey.

BACKGROUND: "Moral distress" describes the psychological strain a provider faces when unable to uphold professional values because of external constraints. Recurrent or intense moral distress risks moral injury, burnout, and physician attrition but has not been systematically studied among neurosurgeons. OBJECTIVE: To develop a unique instrument to test moral distress among neurosurgeons, evaluate the frequency and intensity of scenarios that may elicit moral distress and injury, and determine their impact on neurosurgical burnout and turnover. METHODS: An online survey investigating moral distress, burnout, and practice patterns was emailed to attending neurosurgeon members of the Congress of Neurological Surgeons. Moral distress was evaluated through a novel survey designed for neurosurgical practice. RESULTS: A total of 173 neurosurgeons completed the survey. Half of neurosurgeons (47.7%) reported significant moral distress within the past year. The most common cause was managing critical patients lacking a clear treatment plan; the most intense distress was pressure from patient families to perform futile surgery. Multivariable analysis identified burnout and performing ≥2 futile surgeries per year as predictors of distress (P < .001). Moral distress led 9.8% of neurosurgeons to leave a position and 26.6% to contemplate leaving. The novel moral distress survey demonstrated excellent internal consistency (Cronbach alpha = 0.89). CONCLUSION: We developed a reliable survey assessing neurosurgical moral distress. Nearly, half of neurosurgeons suffered moral distress within the past year, most intensely from external pressure to perform futile surgery. Moral distress correlated with burnout risk caused 10% of neurosurgeons to leave a position and a quarter to consider leaving.

Spinal cord detethering without laminectomy or laminotomy.

BACKGROUND: Tethered cord syndrome occurs when there is abnormal tension on the distal spinal cord, which limits its elevation as patients grow. This results in stretching of the neural elements and microvasculature, resulting in both direct and ischemic injury.[7] Animal studies suggest that impairment of oxidative metabolic pathways may contribute to neuronal injury.[7] Associated conditions include myelomeningocele, lipomyelomeningocele, intraspinal lipomas, diastematomyelia, thickened/fatty filum terminale, and trauma.[2] Tethering may be asymptomatic or result in a variety of symptoms including lower extremity weakness/sensory deficits, bowel/bladder dysfunction, scoliosis, pes cavus, and back/leg pain.[6] Early surgical intervention has been shown to improve outcomes and may be performed prophylactically or to prevent symptom progression.[1,3] More specifically, retrospective studies demonstrate that surgical intervention in patients under the age of 2 years is associated with improved outcomes.[5] In some cases, detethering may result in clinical improvement.[3]. CASE DESCRIPTION: We present a case of a 6-month-old male with a low-lying conus medullaris, lumbar syrinx, mildly abnormal urodynamic studies, and asymmetric utilization of his lower extremities observed during the evaluation of a Y-shaped gluteal cleft. He underwent elective spinal cord detethering via the safe and effective, minimally invasive technique described in the video.The patient's parents gave informed consent for treatment and video recording. Institutional review board approval was deemed unnecessary. CONCLUSION: Given the variety of surgical techniques used for cord detethering, this video may assist other surgeons in developing techniques that require little to no compromise of the developing bony spinal column while achieving sufficient release of the spinal cord.[4].

A Scoping Review of Burnout in Neurosurgery.

BACKGROUND: Burnout is a negative workplace syndrome of emotional exhaustion, cynicism, and perceived professional inefficacy that risks the patient-provider relationship, patient care, and physician well-being. OBJECTIVE: To assimilate the neurosurgical burnout literature in order to classify burnout among domestic and international neurosurgeons and trainees, identify contributory factors, and appraise the impact of wellness programs. METHODS: A scoping review identified the available literature, which was reviewed for key factors related to burnout among neurosurgeons. Two researchers queried PubMed, Embase, Google Scholar, Cochrane, and Web of Science for articles on burnout in neurosurgery and reduced 1610 results to 32 articles. RESULTS: A total of 32 studies examined burnout in neurosurgery. A total of 26 studies examined prevalence and 8 studies detailed impact of wellness programs. All were published after 2011. Burnout prevalence was measured mostly through the Maslach Burnout Inventory (n = 21). In 4 studies, participants defined their own understanding of "burnout." Domestically, burnout prevalence was 11.2% to 67% among residents and 15% to 57% among attendings. Among trainees, poor operative experience, poor faculty relationships, and social stressors were burnout risks but not age, sex, or marital status. Among attendings, the literature identified financial or legal concerns, lack of intellectual stimulation, and poor work-life balance as risks. The impact of wellness programs on trainees is unclear but group exercises may offer the most benefit. CONCLUSION: Noticeable methodological differences in studies on trainee and attending burnout contribute to a wide range of neurosurgery burnout estimates and yield significant knowledge gaps. Environment may have greater impact on trainee burnout than demographics. Wellness programs should emphasize solidarity.

Spinal cord glioblastoma multiforme in a patient with Noonan syndrome: A clinical report.

INTRODUCTION: Currently, there are only 3 reported cases of central nervous system malignancies in patients with Noonan syndrome in the literature, all of which are intracranial pathologies. To our knowledge, there are no cases of spinal cord glioblastoma multiforme reported in the literature. CASE DESCRIPTION: We describe the case of a 12-year-old girl with Noonan syndrome who presented with back pain and new onset neurological deficits and was found to have a spinal cord lesion. T10-L1 laminoplasty with safe maximal resection was done. Postoperative pathological analysis identified this lesion as a high-grade astrocytoma consistent with glioblastoma multiforme. CONCLUSIONS: Spinal cord glioblastoma multiforme is a rare occurrence in the general population, particularly in a patient with an underlying diagnosis of Noonan syndrome. Patients with spinal cord tumors can present with a multitude of clinical signs and symptoms and treatment should not be delayed.

The effect of COVID-19 on trainee operative experience at a multihospital academic neurosurgical practice: A first look at case numbers.

BACKGROUND: COVID-19 has had a significant impact on the economy, health care, and society as a whole. To prevent the spread of infection, local governments across the United States issued mandatory lockdowns and stay-at-home orders. In the surgical world, elective cases ceased to help "flatten the curve" and prevent the infection from spreading to hospital staff and patients. We explored the effect of the cancellation of these procedures on trainee operative experience at our high-volume, multihospital neurosurgical practice. METHODS: Our department cancelled all elective cases starting March 16, 2020, and resumed elective surgical and endovascular procedures on May 11, 2020. We retrospectively reviewed case volumes for 54 days prelockdown and 54 days postlockdown to evaluate the extent of the decrease in surgical volume at our institution. Procedure data were collected and then divided into cranial, spine, functional, peripheral nerve, pediatrics, and endovascular categories. RESULTS: Mean total cases per day in the prelockdown group were 12.26 ± 7.7, whereas in the postlockdown group, this dropped to 7.78 ± 5.5 (P = 0.01). In the spine category, mean cases per day in the prelockdown group were 3.13 ± 2.63; in the postlockdown group, this dropped to 0.96 ± 1.36 (P < 0.001). In the functional category, mean cases per day in the prelockdown group were 1.31 ± 1.51, whereas in the postlockdown group, this dropped to 0.11 ± 0.42 (P < 0.001). For cranial (P = 0.245), peripheral nerve (P = 0.16), pediatrics (P = 0.34), and endovascular (P = 0.48) cases, the volumes dropped but were not statistically significant decreases. CONCLUSION: The impact of this outbreak on operative training does appear to be significant based solely on statistics. Although the drop in case volumes during this time can be accounted for by the pandemic, it is important to understand that this is a multifactorial effect. Further studies are needed for these results to be generalizable and to fully understand the effect this pandemic has had on trainee operative experience.