Women in spine surgery: can we change the society?

BACKGROUND: Although the number of educated women and physicians, and especially neurosurgeons, is increasing worldwide, the educational opportunities, careers, and beliefs concerning female neurosurgeon's status and abilities are undermined. To date, reported studies have focused on the conditions of the work environment, work-life balance, and the academic career of female neurosurgeons. In this study, we aimed to report the patients' viewpoint and how they choose spine physicians. METHODS: We conducted an international survey based on 19 questions in four languages (Bulgarian, Greek, English, and German). The responses of 413 individuals, unrelated to the medical field (sex, 315 female and 115 male individuals; one individual did not answer the question regarding the gender), were obtained. Except for the question regarding the patient's preference for the physician sex, the survey aimed to examine the factors that might be contributing to this choice, including education, age, heard/read recommendations/advertisements, knowledge regarding the work of the neurosurgeons/orthopedists, and their difference regarding spine surgery. RESULTS: The majority of the participants responded that they prefer male surgeons to treat their spine. The results showed a significant correlation between the choice of a male spine surgeon and heard/read advertisements/recommendations and knowledge regarding the work of the neurosurgeon. Despite the fact that education was not related to physician selection, it was an indirect factor that led to the final choice. CONCLUSION: Women in surgery, mainly in neurosurgery, are being treated by society in an unequal way. Female surgeons are still discriminated because of their gender. The most patients prefer female physicians to talk to, but still believe that they are incapable to perform spine surgery. We cannot stop this until we change our mindset and perception of reality.

Risk factors for pediatric glioma.

Brain tumours are a heterogenic group, a subtype of which is arising from glial cells. Pediatric low-grade gliomas are the most common primary CNS tumour group in childhood, representing 25% to over 30% of pediatric CNS tumours. Pediatric high-grade gliomas are relatively rare and have a poor prognosis. Epidemiological studies have reported various potential risk factors, such as demographics, ionizing and nonionizing radiation, allergic conditions, and infections, immunologic, parental, genetic, and developmental risk factors. These risk factors are relatively unclear and understudied; thus, this narrative review aims to summarize all studies connecting risk factors and pediatric gliomas.

"Security dilemma": active immunotherapy before versus after radiation therapy alone or chemo-radiotherapy for newly diagnosed glioblastoma.

Management of glioblastoma should be aggressive and personalised to increase the quality of life. Many new therapies, such as active immunotherapy, increase the overall survival, yet they result in complications which render the search for the optimal treatment stra-tegy challenging.

Gross total resection with fluorescence could lead to improved overall survival rates: a systematic review and meta-analysis.

INTRODUCTION: Glioblastoma cases are often treated with aggressive resection. Recent studies have suggested that extended surgical resection could improve survival. Improved extent of resection could be afforded by the use of fluorescence during surgery. We aimed to examine the effect of fluorescence on the results of gross total resection (GTR) and its impact on the overall survival (OS) and progression-free survival (PFS) rates. METHODS: We performed a literature search of studies published between 2000 and 2021. The study followed the PRISMA guidelines and focused on newly-diagnosed glioblastoma cases. The collected data were divided into two groups according to the fluorescence use: Group A (standard white-light use) and Group B (fluorescent-light use). RESULTS: The results showed a superiority of the fluorescence use during surgery for newly diagnosed glioblastoma cases concerning the procurement of GTR. Additionally, we highlighted the importance of GTR on the OS but not on the PFS rate. We found that the use of 5-aminolevulinic acid resulted in better OS rates compared to fluorescein sodium. CONCLUSION: GTR is a significant factor leading to improved OS; nevertheless, it was an apparently unrelated factor for estimating the PFS rate. Fluorescence use during surgery could lead to higher rates of complete resection and better OS rates.

Vertigo: Could this Symptom Indicate the Existence of an Unruptured Intracranial Aneurysm?

Background:Unruptured intracranial aneurysms (UIAs) can be presented with various symptoms, including atypical headaches and cranial nerve deficits. Vertigo is often referred in the literature as a coexisting symptom. Our aim was to investigate the importance of vertigo in the UIA symptomatology and present a possible explanation for its existence. Methods:We conducted a retrospective observational multicenter study concerning patients with surgically treated intracranial aneurysms. During a period of 10 years, 1 085 patients with cerebral aneurysms underwent surgery. There were 812 patients with ruptured intracranial aneurysms (RIA) and 273 with UIA. The medical records for each of the 273 patients were analyzed. Results: After the implementation of exclusion criteria, 89 (32.6%) of UIA patients were selected in the study, from which 71 (79.8%) were females and 18 (20.2%) males. The mean age was 56.9 (± 12.876) years old. Vertigo existed in 72 (80.9%), headache in 41 (46.1%) and visual symptoms in 21 (23.6%) patients. No significant correlation (p >0.05) was demonstrated between gender, age or aneurysm location in correlation with vertigo, headache or visual symptoms, apart from a negative significant correlation between age and vertigo (p=0.031). Conclusion:Vertigo is an alarming symptom that could indicate the existence of an UIA. The pathophysiological mechanism could be explained by the formation of an aneurysmal vortex that projects into the parent artery, leading to disturbances in the laminar flow and formation of an irregular/turbulent flow, which potentially affects the cerebral autoregulation and by consequence, the central processing of movement.

Anatomical Localization of Traumatic Brain Injury Cases in Eastern Macedonia and Thrace, Greece: a 10-year Retrospective Observational Study.

OBJECTIVE: Brain trauma is an extremely important economical and social issue with increasing daily incidence. It is important to observe and report brain trauma, in order to provide better conditions for improvement of the trauma prevention and management. METHODS: A ten-year retrospective observational analysis was performed on 292 (fatal and non-fatal) incidents of traumatic brain injury among 2,847 totally examined cases in the records of the laboratory of forensic sciences at Democritus University of Thrace between January 1, 2007 and December 31, 2016. The results were further analyzed and classified into pertinent categories associated with the purpose of the study. RESULTS: The average age was estimated at 47.24 years with an obvious male domination. The most common cause of TBI, according to the results, is transport accidents (61.85%) followed by trauma inflicted by blunt instrument (22.49%), fall from height (11.65%) and occupational accidents (4.02%). Mortality rates were evaluated for each type, revealing extremely disturbing numbers. Regarding the anatomical localization on the skull, the most common region of cranial fractures is the cranial base (16.48%), followed by the frontal (12.87%), occipital (11.29%) and parietal bones (11.06%). In the majority of the cases, there were associated injuries. CONCLUSION: The management of traumatic brain injuries is difficult and sometimes impossible. Better prevention measures are required to minimize as much as possible the incidence of brain trauma.

Traumatic Brain Injury and the Importance of Neurosurgical Care: 10-year Retrospective Study on Cadavers.

OBJECTIVE: Traumatic brain injury (TBI) due to transport accidents is a serious cause of death and disability. In every case, however, quick response and a proper health care are required. MATERIALS AND METHODS: We collected 10-year data retrospectively from the laboratory of forensic science and toxicology in Montana, Bulgaria with the intention to show the importance of neurosurgical care in the traumatology and its connection to mortality rate. RESULTS: 124 cadavers were included with significant male predominance. The data analysis shows that the mortality rate at the hospitals without neurosurgical facilities and the mortality at the scene of the accident is the same for traffic brain injuries. Furthermore, we found that the age has no correlation with the mortality rate. CONCLUSION: Road injuries are the most common type of brain injury. We believe that the outcome of these TBIs depends on the availability of a neurosurgical unit.

Does Nationality Matter for the Gunshot Brain Injury? Ten-Year Retrospective Observational Cadaveric Comparative Study for Gunshot TBI between Greece and Bulgaria.

OBJECTIVE: Penetrating brain trauma (PBT) caused by gunshot is one of the most lethal traumatic brain injuries (TBIs) and its management and confrontation is of great importance. METHODS: The authors searched retrospectively the archives from 2 similar autonomous laboratories of forensic science and toxicology in the Balkan peninsula for a 10-year period of time and included only fatal penetrating brain injuries. RESULTS: The study is conducted in 61 cadavers with gunshot PBT. All of the cadavers were victims of suicide attempt. The most common anatomical localization on the skull were the facial bones, followed by skull base, temporal and parietal bone, conducting a trajectory of the gunshot. Additional findings were atherosclerosis of the blood vessels and chronic diseases such as chronic obstructive pulmonary disease, cancer and fatty liver. CONCLUSION: PBI has a high mortality rate. There are factors and findings from the collected data differing between the 2 aforementioned nations. Either way, better preventative measures, gun control and healthcare system are highly necessary.

The Clock Is Ticking - Brain Atrophy in Case of Acute Trauma?

OBJECTIVE: Brain atrophy and brain herniation are gaining a lot of attention separately, but a limited amount of studies connected them together, and because of this, we are going to review and examine the subject in the current meta-analysis. METHODS: The authors collected data reporting brain atrophy of alcoholic and schizophrenic cause, as well as data on control patients, all of which was published on MEDLINE between 1996 and 2018. The included 11 articles were processed with a statistical program. RESULTS: We found that the pericerebral space is unequal among the groups, while the intracranial volume is strongly correlated to the biggest foramen of the body. The effect of this inequality, however, is expressed in emergency cases, where the patients with brain atrophy will have more time before the final stage of brain herniation. CONCLUSION: The current study raises a controversial issue that requires careful investigation and high attention from the health care personnel.

An incidental intracranial lesion in a young woman with head trauma: The key role of CT bone reconstruction in the diagnosis of an osteoma of the anterior cranial fossa.

A young female was subjected to brain CT due to head trauma after a car accident. A lesion was found in the area of the right frontal lobe raising concern. After reconstruction of the CT slices, the radiologic features indicated a skull base osteoma, without the need for further intervention.

Pediatric Dilemma: Endovascular versus Surgical Intervention for Spinal Vascular Malformations.

OBJECTIVE: Spinal arteriovenous malformations (AVM) manifest in the pediatric population very differently from the ones in adulthood. Despite that fact, the treatment strategy is quite the same, which provokes a question - whether some of the therapies have an advantage and if so, in which age group. METHODS: For this reason, the authors searched the world literature between 1989 and 2018 for spinal AVM in children and further categorized the studies into two age groups: < 12 and ≥12. RESULTS: The total number of included studies in this meta-analysis is 35. Seventeen of them are on the subject of AVM and 15 on the subject of arteriovenous fistula. Three studies encompass both types of lesions. CONCLUSION: After processing the data, we observed that there is no relationship between age group and the utilized management, except for the endovascular AVF in children less than 12 years of age. Because of this, it should be strongly considered in further management planning.

Is the Garden Gun (Flobert 9 mm) Capable of Inducing Fatal Injury?: Literature Review and Comparative Presentation of Two Cases.

This article presents both a fatal suicide incident by Flobert 9 mm-type smoothbore weapon with a single-shot projectile and a nonfatal case of a suicide attempt by the same weapon type with a dispersion cartridge from the authors' forensic record. A retrospective study was conducted examining 84 cases involving cases of headshots inflicted by all kinds of weapons deriving from the broader region of Eastern Macedonia and Thrace (Northern Greece) between 2000 and 2015, among which only 1 involved lethal wounding by a Flobert 9 mm (1.19%). Only a single case report of a fatality with such a weapon has been described throughout international literature. A comparative study also follows between the 3 incidents. The authors argue that a prerequisite for the lethal outcome of the shooting is the absolute contact of the weapon to the head as well as its placement at an anatomical point where the bone resistance is relatively lower, so that the intracranial entry of the projectile is possible. It is also more harmful if the cartridge contains a single-shot projectile rather than multiple projectiles of smaller diameter.

The Basic Steps of Evolution of Brain Surgery.

OBJECTIVE AND CONCLUSION: Neurosurgery is probably the most constantly developing specialty of all times. Its dimension is enormous and its history, Ancient. The evolution of neurosurgery from the Mayan and Egyptian periods to the Renaissance and the 21st century was the result of many physicians and patients whose experiences lead to the revolution of modernization. Today, the field of neurosurgery is continuously expanding, aiming to introduce knowledge and technologies that could provide a new futuristic wave of medicine. METHODS: Given this background, our team selected relevant data from Medline published between 1936 and 2017. RESULTS: We included 91 articles on this topic, all of them providing enough information about the revolution and progress of brain surgery through the centuries as well as its potential expansion in the future.

Traumatic Brain Injury Due to Screwdriver Assaults: Literature Review and Case Report.

Penetrating head injuries due to the use of screwdrivers as wounding agents in acts of interpersonal violence seldom occur. The aim of this article is to update and summarize the relevant literature on penetrating craniocerebral screwdriver stab wounds and to report a new case of screwdriver assault. A number of studies were reviewed to investigate the incidence, distribution, common findings, mechanism of injury, differential diagnostic criteria, complications, treatment, and prognosis of craniocerebral screwdriver stab injuries. It was observed that the degree of traumatic severity depends on the cross-sectional area of the screwdriver and the anatomical region of injury. Craniocerebral screwdriver injuries are mainly cases of interpersonal violence and the mortality rate is approximately 47.6%. In 23.8% of the incidents, the trauma is overlooked on admission because of the small entry wound and, thus, the severity of the injury is not initially appreciated.

Fatal accident due to anti-personnel ARGES EM01 rifle grenade explosion.

During the process of unsealing an old ammunition box in order to destroy it, a 42-year-old ammunition technician was fatally injured due to an anti-personnel ARGES EM01-type rifle grenade detonation. The explosion took place in the victim's hands, in point-blank range. This report aimed to show the anatomical position, the severity and the dispersion extent of the multiple injuries in the human body due to the detonation, and draw firm conclusions regarding the position of the human body and the circumstances prevailing at the moment of the explosion.

Prediction of Lumbar Disc Herniation Patients' Satisfaction with the Aid of an Artificial Neural Network.

AIM: To identify key determinants of lumbar disc herniation (LDH) patients' satisfaction and to evaluate the efficiency of an artificial neural network (ANN) model to prognosticate satisfaction derived from the hospital stay in this specific patient group. MATERIAL AND METHODS: A single item question was used to assess patient satisfaction. Principal component analysis evaluated several aspects of care (15 items). An ANN encompassed all variables and its prediction ability was tested. The ANN performance was correlated to a binary logistic regression (BLR) model. RESULTS: Higher levels of satisfaction were reported by females, older patients, Greeks, and patients with elementary education staying in not rural areas. A history of a single previous hospitalisation was correlated with more satisfaction. The accuracy of ANN was 96% for satisfaction prediction outperforming the BLR model. CONCLUSION: Satisfactory health services are influenced by sex, age, nationality, and number of prior admissions. The self-perceived health state plays also a crucial role. The current study is the first one reporting on the capability of an ANN to accurately predict the satisfaction levels of LDH patients.

An atypical meningioma demystified and advanced magnetic resonance imaging techniques.

A 40-year-old male presented with visuospatial processing disturbances. Family history was free. Conventional and advanced magnetic resonance imaging (MRI) studies were performed. On T2 and fluid attenuation inversion recovery images, an increased signal intensity extra-axial lesion was demonstrated. Post-contrast scans depicted homogeneous intense contrast medium enhancement. T2* star sequence was negative for hemorrhagic or calcification foci. Diffusion-weighted imaging findings were indicative of malignant behavior and magnetic resonance venography confirmed superior sagittal sinus infiltration. Increased cerebral blood volume values were observed and peri-lesional oedema on perfusion-weighted imaging was also demonstrated. The signal intensity-time curve depicted the characteristic meningioma pattern. Spectroscopy showed increased choline and alanine levels, but decreased N-acetyl-aspartate levels. Conventional MRI is adequate for typical types of meningiomas. However, the more atypical ones, in which even the histopathologic specimen may demonstrate characteristics of typical meningioma, could be easier diagnosed with advanced MRI techniques.