Neurosurgery training in India during the COVID-19 pandemic: straight from the horse's mouth.

OBJECTIVE: The COVID-19 pandemic has forced medical professionals throughout the world to adapt to the changing medical scenario. The objective of this survey was to assess the change in neurosurgical training in India following the COVID-19 pandemic. METHODS: Between May 7, 2020, and May 16, 2020, a validated questionnaire was circulated among neurosurgical residents across India by social media, regarding changes in the department's functioning, patient interaction, surgical exposure, changes in academics, and fears and apprehensions associated with the pandemic. The responses were kept anonymous and were analyzed for changes during the COVID-19 pandemic compared to before the pandemic. RESULTS: A total of 118 residents from 29 neurosurgical training programs across 17 states/union territories of the country gave their responses to the survey questionnaire. The survey revealed that the surgical exposure of neurosurgical residents has drastically reduced since the onset of the COVID-19 pandemic, from an average of 39.86 surgeries performed/assisted per month (median 30) to 12.31 per month (median 10), representing a decrease of 67.50%. The number of academic sessions has fallen from a median of 5 per week to 2 per week. The survey uncovered the lack of universal guidelines and homogeneity regarding preoperative COVID-19 testing. The survey also reveals reluctance toward detailed patient examinations since the COVID-19 outbreak. The majority of respondents felt that the COVID-19 pandemic will hamper their operative and clinical skills. Fear of rescheduling or deferring of licensing examinations was significantly higher among those closest to the examination (p = 0.002). CONCLUSIONS: The adverse impact of the pandemic on neurosurgical training needs to be addressed. While ensuring the safety of the residents, institutes and neurosurgical societies/bodies must take it upon themselves to ensure that their residents continue to learn and develop neurosurgical skills during these difficult times.

Is Minimally Invasive Spinal Surgery Superior to Endoscopic Spine Surgery in Postoperative Radiologic Outcomes of Lumbar Spine Degenerative Disease? A Systematic Review.

BACKGROUND: Minimally invasive spinal surgery (ESS) are both well-established surgical techniques for lumbar spinal stenosis; however, there is limited literature comparing the efficacy of the two techniques with respect to radiologic decompression data. METHODS: In this review, PubMed, Google Scholar, and Scopus databases were systematically searched from inception until July 2022 for studies that reported the radiologic outcomes of endoscopic and minimally invasive approaches for decompressive spinal surgery, namely, the spinal canal area, neural foraminal area, and neural foraminal heights. RESULTS: Of the 378 articles initially retrieved using MeSH and keyword search, 9 studies reporting preoperative and postoperative spinal areas and foraminal areas and heights were finally included in our review. Of the total 581 patients, 391 (67.30%) underwent MISS and 190 (32.70%) underwent ESS. The weighted mean difference between the spinal canal diameter in pre- and postoperative conditions was 56.64 ± 7.11 and 79.52 ± 21.31 mm2 in the MISS and ESS groups, respectively. ESS was also associated with a higher mean difference in the foraminal area postoperatively (72 ± 1 vs. 35.81 ± 11.3 mm2 in the MISS and ESS groups, respectively), but it was comparable to MISS in terms of the foraminal height (0.32 ± 0.037 vs. 0.29 ± 0.03 cm in the MISS and endoscopic groups, respectively). CONCLUSIONS: Compared with MISS, ESS was associated with improved radiologic parameters, including spinal canal area and neural foraminal area in the lumbar spinal segments. Both techniques led to the same endpoint of neural decompression when starting with a more severe compression. However, the present data do not allow the correlation of the radiographic results with the related clinical outcomes.

Synchronous Carotid Body and Glomus Jugulare Tumors : A Case Report and Review of Literature.

Paragangliomas are rare neuroendocrine tumors that are usually benign in nature. They may be either familial or sporadic in their occurrence. Numerous neuroendocrine tumors are collectively included under the umbrella of paragangliomas. Among them, carotid body tumors and glomus jugulare tumors are extremely rare. Thus, we present a rare case of 29-year-old male who was admitted with hearing difficulties and tinnitus in the left ear, with swelling on the left side of the neck. Based on clinical and radiological findings, a diagnosis of left-sided glomus jugulare with carotid body tumor was made. The patient underwent a twostage surgery with an interval of approximately 2 months. Histopathology revealed a paraganglioma. Herein, we present the clinical features, imaging findings, management, and a brief review of literature on the classification, evaluation, and management of carotid body and glomus jugulare tumors. Paraganglioma is a slow-growing tumor. The synchronous occurrence of carotid body and glomus jugulare tumors is infrequent. Microsurgical resection remains the primary treatment modality. Therefore, our patient underwent two-stage surgery. The rarity of occurrence and the proximity and adherence to vital neurovascular structures have resulted in the treatment of paragangliomas remaining a challenge.

Assessing the impact of mixed reality-assisted informed consent: A study protocol.

Background: Informed consent is a crucial aspect of modern medicine, but it can be challenging due to the complexity of the information involved. Mixed reality (MR) has emerged as a promising technology to improve communication. However, there is a lack of comprehensive research on the impact of MR on medical informed consent. The proposed research protocol provides a solid foundation for conducting future investigations and developing MR-based protocols that can enhance patients' understanding and engagement in the decision-making process. Methods: This study will employ a randomized controlled trial design. Two arms will be defined: MR-assisted informed consent (MRaIC) as the experimental arm and conventional informed consent (CIC) as the control arm consent, with 52 patients in each group. The protocol includes the use of questionnaires to analyze the anxiety levels and the awareness of the procedure that the patient is going to perform to study the impact of MRaIC versus CIC before medical procedures. Results: The study will evaluate the impact of MR on patients' information comprehension, engagement during the process of obtaining informed consent, emotional reactions, and consent decisions. Ethical concerns will be addressed. Conclusion: This study protocol provides a comprehensive approach to investigate the impact of MR on medical informed consent. The findings may contribute to a better understanding of the effects of MR on information comprehension, engagement during the process of obtaining informed consent, psychological experience, consent decisions, and ethical considerations. The integration of MR technology has the potential to enhance surgical communication practices and improve the informed consent process.

Giant Tarlov Cyst presenting as pelvic mass: Often doing less is better.

Background: Tarlov cysts are sacral perineural cysts arising between the peri and endoneurium of the posterior spinal nerve root at the Dorsal Root Ganglion and have a global prevalence rate of 4.27%. These are primarily asymptomatic (only 1% with symptoms) and typically arise in females between the ages of 50-60. Patients' symptoms include radicular pain, sensory dysesthesias, urinary and/or bowel symptoms, and sexual dysfunction. Non-surgical management with lumbar cerebrospinal fluid drainage and computerized tomography-guided cyst aspiration typically provide only months of improvement before recurring. Surgical treatment includes a laminectomy, cyst, and/or nerve root decompression with fenestration of the cyst and/ or imbrication. Early surgery for large cysts provides the longest symptom-free periods. Case Description: A 30-year-old male presented with a very large magnetic resonance-documented Tarlov cyst (Nabors Type 2) arising from bilateral S2 nerve root sheaths with marked pelvic extension. Although he was initially treated with a S1, S2 laminectomy, closure of the dural defect, and excision/marsupialization of the cyst, he later required placement of a thecoperitoneal shunt (TP shunt). Conclusion: A 30-year-old male with large Nabors Type 2 Tarlov cyst arising from both S2 nerve root sheaths required a S1-S2 laminectomy, dural closure/marsupialization, and imbrication of the cyst, eventually followed by placement of a TP shunt.

Comparison of Staged Stereotactic Radiosurgery and Fractionated Stereotactic Radiotherapy in Patients with Brain Metastases > 2 cm without Prior Whole Brain Radiotherapy: A Systematic Review and Meta-Analysis.

OBJECTIVE: To compare fractionated stereotactic radiotherapy (FSRT) with staged stereotactic radiosurgery (SSRS) in patients with brain metastases >2 cm without prior whole brain radiotherapy. METHODS: In this systematic review and meta-analysis, PubMed, Scopus, Web of Science, Embase, and Cochrane were searched to include studies that evaluated FSRT and/or SSRS for brain metastases >2 cm or 4 cm3 in adult patients with a known primary malignancy and no prior history of whole brain radiotherapy. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed and an indirect random-effect meta-analyses was conducted to compare treatment outcomes between the two modalities. RESULTS: A total of 10 studies were included, comprising 612 (778 metastases) and 250 patients (265 metastases) in the SSRS and FSRT groups, respectively. The SSRS group had significantly older patients (66.6 ± 17.51 years vs. 62.37 ± 37.89 years; P = 0.029) with lower rate of control of primary disease (11.59% vs. 78.7%, P < 0.00001), and more patients with Karnofsky performance status ≥70 at baseline (92.81% vs. 88.56%; P = 0.045). FSRT was associated with a statistically nonsignificant but clinically important lower 12-month overall survival (44.75% [95% confidence interval [CI]: 30.48%-59.95%] vs. 53.25% [95%CI: 45.15%-61.19%], P = 0.1615) and higher rate of salvage radiotherapy (18.18% [95%CI: 8.75%-34%] vs. 12.27% [95%CI: 5.98%-23.53%], P = 0.0841). Both groups had comparable rates of local tumor control, mortality, tumor progression, recurrence, neurological death, and 6-month overall survival. CONCLUSIONS: SSRS and FSRT were found to be comparable for treating brain metastases >2 cm not previously irradiated. Given the paucity of such studies, trials directly comparing the two treatment strategies are warranted to support these findings.

Considerations on surgery invasiveness and response and toxicity patterns in classic palliative radiotherapy for acrometastases of the hand: a hint for a potential role of stereotactic body radiation therapy? A case report and literature review.

Background: The rarity of hand acrometastases hampers the consensus-building for their optimal management among the involved oncology professionals. In the current literature, demolitive surgery overcomes the use of palliative radiotherapy, which proved to be ineffective in more than 30% of cases treated with classic palliative dose schemes, carrying also a not negligible radiation-related adverse event rate. Against this background, stereotactic body radiation therapy (SBRT) could emerge as a well-balanced therapeutic option. Case summary: Here we describe the methods and outcomes of a SBRT treatment of a painful and function-limiting hand acrometastasis in a patient with a history of stage IIIB lung adenocarcinoma. We delivered a total dose of 30 Gy in five daily fractions to a soft-tissue metastasis abutting the fifth metacarpal bone through the SBRT protocol generally used for intracranial treatments. A few weeks later, the patient reported a clinical complete response with acrometastasis and pain disappearance, function recovery, and no significant toxicity. The acrometastasis was the first sign of an atypical cancer progression. Conclusions: SBRT for hand acrometastases is feasible and might have the best therapeutic profile among the currently available treatment options for this rare clinical scenario. Larger investigations are needed to confirm the present single-case experience.

Introducing Radiotherapy in Metastatic Merkel Cell Carcinoma Patients with Limited Progression on Avelumab: An Effective Step against Primary and Secondary Immune Resistance?

PURPOSE: To investigate the ability of radiotherapy (RT) to prolong progression-free survival (PFS) and to report treatment-related toxicities among oligoprogressive metastatic Merkel cell carcinoma (mMCC) patients on avelumab. METHODS: We retrospectively collected clinical data on mMCC patients who underwent radiotherapy for limited progression on avelumab. Patients were categorized as primary or secondary immune refractory depending on the time of onset of resistance to immunotherapy (at the first or subsequent follow-up visits after avelumab initiation). Pre- and post-RT PFS were calculated. Overall survival (OS) from the first progression treated with RT was also reported. Radiological responses and toxicities were evaluated according to the irRECIST criteria and RTOG scoring system, respectively. RESULTS: Eight patients, including five females, with a median age of 75 years, met our inclusion criteria. The median gross tumor and clinical target volumes at first progression on avelumab were 29.85 cc and 236.7 cc, respectively. The treatment sites included lymph node, skin, brain, and spine metastases. Four patients received more than one course of RT. Most patients were treated with palliative radiation doses (mainly 30 Gy in 3 Gy/day fractions). Two patients were treated with stereotactic RT. Five/eight patients were primary immune refractory. The objective response rate at the first post-RT assessment was 75%, whereas no local failure was reported. The median pre-RT PFS was 3 months. The pre-RT PFS was 37.5% at 6 months and 12.5% at 1 year. The median post-RT PFS was not reached. The post-RT PFS was 60% at 6 months and 1 year. The post-RT OS was 85.7% at 1 year and 64.3% at 2 years. No relevant treatment-related toxicity was observed. After a median follow-up of 18.5 months, 6/8 patients are still alive and continuing on avelumab therapy. CONCLUSIONS: Adding radiotherapy to mMCC patients with limited progression on avelumab seems to be safe and effective in prolonging the successful use of immunotherapy, regardless of the type of immune refractoriness.

Detection of "Incidentalomas" on Brain and Body 68Ga-DOTATOC-PET Scans: A Retrospective Study and Case Illustration.

BACKGROUND/AIM: One of the main limitations of standard imaging modalities is microscopic tumor extension, which is often difficult to detect on magnetic resonance imaging (MRI) and computer tomography (CT) in the early stages of the tumor. (68)Ga-DOTA(0)-Phe(1)-Tyr(3)-octreotide positron-emission tomography/computed tomography (68Ga-DOTATOC PET/CT) has shown efficacy in detecting lesions previously undiagnosed by neuroimaging modalities, such as MRI or CT, and has enabled the detection of multiple benign tumors (like multiple meningiomas in a patient presenting with a single lesion on MRI) or additional secondary metastatic locations. PATIENTS AND METHODS: We retrospectively reviewed data from the Cannizzaro Hospital on brain and body 68Ga-DOTATOC PET/CT "incidentalomas", defined as tumors missed on CT or MRI scans, but detected on 68Ga-DOTATOC PET/CT scans. "Incidentalomas" were classified into "brain" and "body" groups based on their location. The standardized uptake values (SUVs) were compared between the two groups. RESULTS: A total of 61 patients with "incidentalomas" documented on the 68Ga-DOTATOC PET/CT were identified: 18 patients with 25 brain lesions and 43 patients with 85 body lesions. The mean SUV at baseline was 9.01±7.66 in the brain group and 14.8±14.63 in the body group. CONCLUSION: We present the first series on brain and body "incidentalomas" detected on 68Ga-DOTATOC PET/CT. Whole-body 68Ga-DOTATOC PET/CT may be considered in selected patients with brain tumors with high expression of somatostatin receptors to assist radiosurgical or surgical planning and, simultaneously, provide accurate follow-up with early detection of potential metastases.

Coma recovery scale: Key clinical tool ignored enough in disorders of consciousness.

BACKGROUND: Disorders of consciousness (DoC) includes coma, vegetative state (VS), minimally conscious state (MCS), and emergence from the MCS. Aneurysmal rupture with high-grade SAH, traumatic brain injury, and neoplastic brain lesions are some of the frequent pathologies leading to DoC. The diagnostic errors among these DoC are as high as ranging from 25% to 45%, with a probable error in the conclusion of patients' state, treatment choice, end-of-life decision-making, and prognosis. Some studies also reported that 37-43% of patients were misdiagnosed in VS while demonstrating signs of awareness. Despite its wide acceptance, Coma Recovery Scale-Revised (CRS-r) remained underused or inappropriately utilized, which may lead to substandard or unprofessional patient care. Literature is rare on the knowledge of CRS-r among physicians published from India and across the globe. Therefore, we carried out the present study to ascertain physicians' knowledge on CRS-r and raise awareness about its justifiable clinical utilization. We also explored the factors associated with this perceived level of experience among participants and recommend frequent physicians' training for care of patients with DoC. METHODS: An institution-based cross-sectional online survey was conducted from June 8 to July 7, 2020, among Ninety-six physicians recruited using a convenient sampling technique. Twenty-item, validated, reliable, and a pilot-tested questionnaire was used to assess the knowledge regarding CRS-r and collect socio-demographic variables. The analysis was performed using the Statistical Package for the Social Sciences version 23. Bivariate and multivariate logistic regression analyses were employed to assess the association of participants' socio-demographic variables and their parent department of work with the knowledge. P < 0.05 was considered statistically significant in the multivariate analysis. RESULTS: A total of Ninety-six participants were included in the analysis, and only 33.3% of them were found to have adequate knowledge of CRS-r. Multivariate analysis revealed that age (adjusted odds ratio [AOR] = 31.66; 95% CI: 6.25-160.36), gender (AOR = 44.16; 95% CI: 7.43-268.23), and parent department of working (AOR = 0.148; 95% CI: 0.06-0.39) were significantly associated with the knowledge. CONCLUSION: Knowledge of the physicians on CRS-r is found to be exceptionally low. It has a strong tendency to adversely affect patients' optimal care with disorders of consciousness (DoC). Therefore, it is crucial to expand physicians' knowledge and awareness regarding CRS-r to adequately screen patients with DoC.

Collateral damage caused by COVID-19: Change in volume and spectrum of neurosurgery patients.

BACKGROUND: There has been a dramatic change in the pattern of patients being seen in hospitals and surgeries performed during the ongoing COVID-19 pandemic. The objective of this study is to study the change in the volume and spectrum of surgeries performed during the ongoing COVID-19 pandemic compared to pre-COVID-19 era. METHODS: Details of all patients who were operated under department of neurosurgery at our institute since the onset of COVID-19 pandemic in India were collected and compared to the same time period last year. The demographic profile, diagnosis, surgery performed, type of surgery (routine/emergency, cranial/spinal and major/minor) in these two groups were compared. They were further categorized into various categories [neuro-oncology (brain and spine tumors), neuro-trauma (head injury and spinal trauma), congenital cases, degenerative spine, neuro-vascular, CSF diversion procedures, etc.] and compared between the two groups. RESULTS: Our study showed a drastic fall (52.2%) in the number of surgeries performed during the pandemic compared to pre-COVID era. 11.3% of patients operated during COVID-19 pandemic were non-emergent surgeries compared to 57.7% earlier (p = 0.000). There was increase in proportion of minor cases from 28.8% to 41.5% (p = 0.106). The proportion of spinal cases decreased from 27.9% to 11.3% during the COVID-19 pandemic (p = 0.043). CONCLUSIONS: The drastic decrease in the number of surgeries performed will result in large backlog of patients waiting for 'elective' surgery. There is a risk of these patients presenting at a later stage with progressed disease and the best way forward would be to resume work with necessary precautions and universal effective COVID-19 testing.

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.

Impact of the COVID-19 Pandemic on Neurosurgical Practice in India: Results of an Anonymized National Survey.

BACKGROUND: The COVID-19 pandemic has created an unprecedented challenge for medical professionals throughout the world to tackle the rapidly changing scenario. The objective of this survey was to analyze the change in neurosurgical practice in India following the COVID-19 outbreak and assess its impact on practising neurosurgeons. MATERIALS AND METHODS: Between May 7th and 23rd, 2020, a validated questionnaire was circulated amongst practising neurosurgeons across the country by social media and e-mails, regarding changes in the patterns of patients seen, adaptations made in their practice, effect on surgeries performed, financial burden, and impact on their personal lives. The responses were kept anonymous and were analyzed for correlations between the changes observed and independent factors such as hospital affiliations, teaching professions, and neurosurgical experience. RESULTS: Our survey showed a drastic fall in the number of neurosurgical patients seen in the outpatient department (OPD) as well as the number of surgeries performed. A drop of 76.25% was seen in OPD patients (P = 0.000) and that of 70.59% in surgeries performed (P = 0.000). There was no uniformity among the neurosurgeons in the number of COVID-19 tests being done before elective/emergency surgery and in the use of protective gear while examining patients. Private practitioners were more affected financially as compared to those in the government sector. The pandemic has affected the research work of 53.23% of all respondents, with those in the teaching profession (70.96%) more affected than those in the non-teaching profession (24.67%). CONCLUSIONS: Evidence-based policies, screening COVID-19 tests with better sensitivity, and better-quality personal protective equipment kits in adequate numbers are required to protect our medical professionals from COVID-19. Mental health issues among neurosurgeons may also be an issue, this being a high risk speciality and should be closely watched for.

Gestational gigantomastia with spontaneous resolution in an Indian woman.

We present the case of a 20-year-old woman, primigravida with 24 weeks of amenorrhoea due to pregnancy. She came with symptoms of rapidly increasing size of both the breasts since 8 weeks. On examination, both breasts were grossly enlarged, right more than left, with the level of the nipples reaching beyond the level of the umbilicus. Breast circumference was measured to be 72 cm on the right, and left breast was 66 cm. No palpable lumps in both breasts. No axillary lymphadenopathy noted. Hormonal studies were found to be within the normal range. The pregnancy was terminated due to pre-eclampsia. The patient opted for regular follow-up and observation. While regularly following up, the size of both breasts was observed to gradually reduce to a circumference of 40 cm on the right and 30 cm on the left.