Neurosurgery residency and fellowship education in the United States: 2 decades of system development by the One Neurosurgery Summit organizations.

The purpose of this report is to chronicle a 2-decade period of educational innovation and improvement, as well as governance reform, across the specialty of neurological surgery. Neurological surgery educational and professional governance systems have evolved substantially over the past 2 decades with the goal of improving training outcomes, patient safety, and the quality of US neurosurgical care. Innovations during this period have included the following: creating a consensus national curriculum; standardizing the length and structure of neurosurgical training; introducing educational outcomes milestones and required case minimums; establishing national skills, safety, and professionalism courses; systematically accrediting subspecialty fellowships; expanding professional development for educators; promoting training in research; and coordinating policy and strategy through the cooperation of national stakeholder organizations. A series of education summits held between 2007 and 2009 restructured some aspects of neurosurgical residency training. Since 2010, ongoing meetings of the One Neurosurgery Summit have provided strategic coordination for specialty definition, neurosurgical education, public policy, and governance. The Summit now includes leadership representatives from the Society of Neurological Surgeons, the American Association of Neurological Surgeons, the Congress of Neurological Surgeons, the American Board of Neurological Surgery, the Review Committee for Neurological Surgery of the Accreditation Council for Graduate Medical Education, the American Academy of Neurological Surgery, and the AANS/CNS Joint Washington Committee. Together, these organizations have increased the effectiveness and efficiency of the specialty of neurosurgery in advancing educational best practices, aligning policymaking, and coordinating strategic planning in order to meet the highest standards of professionalism and promote public health.

Lies, damned lies, and statistics: a neurosurgical perspective on the international randomized trial of extracranial to intracranial arterial bypass surgery.

The abrupt occurrence of a devastating stroke has been referred to as "super death." It has long been realized that ischemic cerebral vascular disease may become symptomatic with a wide variety of clinical patterns. A robust circle of Willis has been recognized for its major protective function in many cases. When it became possible to actually create new collateral circulation to the brain by microsurgical techniques, significant enthusiasm arose. This enthusiasm was interrupted by the negative results of the international randomized trial. Further analysis of the trial raised serious questions regarding incomplete randomization by contributors to the study, and there remains uncertainty about important potential benefits for some individuals. Long-term follow-up of 3 patients having different and complex circumstances is described to emphasize this concern. After the creation of reliable collateral circulation to the brain, none has experienced new ischemic deficit during the subsequent follow-up of 27, 25, and 12 years, respectively.

Culture-Negative intracerebral abscesses in children and adolescents from Streptococcus anginosus group infection: a case series.

We report the use of 16S ribosomal RNA gene amplification and sequencing to diagnose culture-negative intracerebral abscesses in younger patients. These 3 cases demonstrate the optimal application of gene sequencing from direct specimens for patients with negative culture results compromised by antibacterial therapy but histories highly suggestive of acute bacterial infection.

The preauricular subtemporal approach for transcranial petrous apex tumors.

OBJECTIVE: To review our series of 51 patients with transcranial petrous apex tumors who were surgically managed through a preauricular subtemporal approach. STUDY DESIGN: A retrospective analysis of patient medical records. SETTING: Tertiary care academic medical center. PATIENTS: All patients with transcranial petrous apex tumors who were surgically treated between July 1988 and July 2005 with a preauricular subtemporal approach. INTERVENTION: The preauricular subtemporal approach with preservation of hearing was used in all 51 cases. MAIN OUTCOME MEASURES: The degree of tumor resection and long-term results. RESULTS: Total tumor resection was achieved in 45 patients, and tumor was left in the cavernous sinus in 6 cases. Magnetic resonance imaging surveillance revealed no recurrent tumor in 36 patients, stable residual disease in 5 cases, and regrowth of tumor in 10 individuals (mean follow-up, 8.8 yr). DISCUSSION: The postauricular infratemporal fossa approach allows adequate exposure to the petrous apex but with the expense of conductive hearing deficit. The preauricular subtemporal approach allows wide access for transcranial petrous apex tumors with preservation of hearing. Tumor control using this approach was achieved in 41 (80%) of 51 of the patients in this series.

Thirty-year follow-up after extracranial-intracranial bypass surgery.

The conventional wisdom resulting from the international, multicenter, trial of extracranial-intracranial bypass surgery is that this procedure offers no benefit. Because of the complex and unique circumstances of some, clinical experience and judgment must sometimes overrule some statistical conclusions.

Facial paralysis associated with glomus jugulare tumors.

OBJECTIVE: To review the intraoperative findings and facial nerve management in nine patients who presented with facial paralysis associated with glomus jugulare tumors. STUDY DESIGN: A retrospective analysis of patient medical records. SETTING: Tertiary care academic medical center. PATIENTS: All patients who presented with facial paralysis and a glomus jugulare tumor who underwent surgical resection of their tumors at our institution. INTERVENTION: A postauricular infratemporal fossa approach for tumor removal and greater auricular interposition neural repair. MAIN OUTCOME MEASURE: Intraoperative facial nerve findings and long-term facial recovery. RESULTS: One hundred two patients underwent a postauricular infratemporal approach for resection of glomus jugulare tumor from July 1988 through July 2005. Nine of these patients presented with ipsilateral facial paralysis. The medial surface of the vertical segment was invaded by tumor in all nine cases. Facial recovery at 2 years was House-Brackmann Grade III in eight patients and Grade IV in one individual. Facial recovery did not significantly change after 2 years (mean follow-up of 7.4 years). DISCUSSION: Facial nerve invasion of the vertical segment occurred in 9 (9%) of 101 patients in our series. Facial nerve resection with interposition grafting resulted in House-Brackmann Grade III in eight (89%) of nine patients. Facial nerve dissection and preservation was not possible when preoperative facial paralysis was evident.

Intratemporal Grafting of the Facial Nerve following Lateral Skull Base Tumor Resection.

UNLABELLED: Intratemporal skull base tumors may invade the facial nerve in the horizontal (tympanic) or descending (vertical) segments, while parotid malignancies typically infiltrate the facial nerve at the stylomastoid foramen. This article will describe our results following intratemporal facial nerve grafting in 44 patients. METHODS: This was a retrospective analysis of 44 patients requiring intratemporal facial nerve repair following lateral skull base tumor resection at our tertiary care, academic medical center. RESULTS: Tumor histology included 17 parotid cancers, 13 temporal bone malignancies, 9 glomus tumors, 3 facial neuromas, and 2 endolymphatic sac tumors. The greater auricular nerve was used in 25 patients and the sural nerve was used in 19 cases. Forty patients were available for facial function assessment at 2 years. Using the House-Brackmann (H-B) recovery scale, the breakdown of patients by facial function was as follows: Grade I, 0 patients; Grade II, 4 patients; Grade III, 29 patients; Grade IV, 4 patients; Grade V, 3 patients; and Grade VI, 0 patients. CONCLUSIONS: Facial paralysis may occur from intrinsic or external lateral skull base invasion of the facial nerve. Intratemporal interposition grafting resulted in favorable facial function (H-B II or III) in 33 of the 40 (82.5%) patients at the 2-year assessment.

Current options in clipping versus coiling of intracranial aneurysms: to clip, to coil, to wait and watch.

Treatment of intracranial aneurysms involves many factors: patient preference and demographics; aneurysm size, site, geometry, access, and intrinsics; practitioner experience and availability; facility; technology; and ancillaries. Volume counts, teamwork enhancement, and management should be individualized.

Hemicraniectomy and durotomy for malignant middle cerebral artery infarction.

Decompressive surgery with hemicraniectomy and durotomy for malignant MCA infarction remains a salvage procedure but can be associated with reasonable clinical outcomes in highly selected patients. This selection of patients appropriate for intervention is of the utmost importance, but exact criteria remain to be defined; older age and increased numbers of associated medical comorbidities seem to define a group of patients who would not derive long term benefit, however. The determination as to whether or not surgery is equally beneficial for dominant or nondominant hemispheric infarction is hampered by lack of good comparative data, but selected case series suggest that some patients who have dominant hemispheric infarction achieve a reasonable degree of independence. Although a well-defined principle of stroke practice is that "time is brain," there are no clear data as to when intervention should be done, as there are some patients who have large MCA infarction and who may not progress to cerebral herniation. Clinicians managing the growing population of patient status post hemicraniectomy should also be aware of this process of the syndrome of the trephined and the potential for resolution that may prompt earlier cranial reconstruction. At present, the decision to proceed with this aggressive intervention of hemicraniectomy and durotomy for large ischemic infarction remains a case-by-case individualized approach, based on patient and family preferences and clinicians' subjective perspective as to patients' potential for clinical recovery.

Intracranial schwannomas of the lower cranial nerves.

OBJECTIVE: To present our experience in the diagnosis and management of 39 patients with lower cranial nerve schwannomas of the posterior fossa. STUDY DESIGN: A retrospective chart review of patient medical records. SETTING: Tertiary care, academic medical center. PATIENTS: All patients with intracranial lower cranial nerve schwannomas treated surgically in our institution between July 1998 and July 2005. INTERVENTION: A retrosigmoid, transcondylar, or combined approach was used for tumor recurrence. RESULTS: Thirty-nine patients underwent surgical resection, with complete tumor removal in 32, near-total resection in 5 patients, and subtotal tumor excision in 2 patients. Long-term (mean, 8.2 years) magnetic resonance imaging surveillance demonstrated recurrent tumor in 2 of 32 complete resections and slow regrowth in 2 of 7 patients with known residual disease. Only one of these four patients required reoperation. DISCUSSION: Intracranial schwannomas of the lower cranial nerves are relatively uncommon and may present with subtle or no clinical symptoms. Successful surgical resection with low risk of tumor recurrence can be achieved with the retrosigmoid or transcondylar approach. Morbidity, in this series, was primarily related to lower cranial nerve deficits.

Morphine/ondansetron PCA for postoperative pain, nausea, and vomiting after skull base surgery.

OBJECTIVE: Patients who underwent skull base procedures have been noted to experience appreciable pain. This study examines pain after surgery and the effectiveness of patient controlled analgesia (PCA) with combination morphine ondansetron for analgesia and control of emesis. STUDY DESIGN AND SETTING: A total of 120 skull base surgery patients were randomized to receive placebo, morphine, or morphine ondansetron. Demographic and intraoperative variables were recorded along with pain, nausea, vomiting, and rescue analgesics. Total PCA use, hospital stay, satisfaction, and cost were also compared. RESULTS: Demographically the groups were similar. Pain was elevated with placebo PCA, and this group averaged twice as many analgesic rescues. Total usage time was lower with placebo PCA. Morphine ondansetron PCA had the lowest pain score with highest satisfaction. Nausea and vomiting was similar but female patients had more vomiting regardless of PCA group. CONCLUSIONS AND SIGNIFICANCE: The use of morphine PCA reduced pain and did not appreciably increase nausea or vomiting. The addition of ondansetron produced no real benefit and its PCA use cannot be justified. EBM RATING: A-1b.

Combined transtemporal access for large (>3 cm) meningiomas of the cerebellopontine angle.

OBJECTIVES: Large meningiomas of the cerebellopontine angle present a formidable surgical challenge due to tumor vascularity, neural attachment, and brain stem compression. The purpose of this paper is to present our use of the combined transtemporal approach in the surgical treatment of 29 large meningiomas. STUDY DESIGN AND SETTING: Twenty-nine patients with large meningiomas of the CPA were surgically treated through a combined retrosigmoid-transpetrosal-transcochlear approach at our tertiary care academic medical center from July 1995 through July 2004. Data was collected from a retrospective medical records review. RESULTS: Total tumor removal was achieved in 19 of 29 (67%) of the patients and the facial nerve was anatomically preserved in 26 of 29 (89%) of the cases. Cerebrospinal fluid leakage was seen in 3.5% of the patients and additional transient cranial nerve deficits were noted in 14% of the cases, but no significant neurologic sequelae occurred. Of the 10 patients with residual tumor, 6 have been stable without growth, 2 were treated with reoperation for regrowth of disease, and 2 were controlled with localized radiotherapy. CONCLUSIONS: This combined lateral transtemporal approach provided wide exposure to the cerebellopontine angle and optimized the surgical extirpation of 29 large meningiomas presented in this series. EBM RATING: C-4.

Factors Influencing the Management of Unruptured Intracranial Aneurysms.

Background Deciding how to manage an unruptured intracranial aneurysm can be difficult for patients and physicians due to controversies about management. The decision as to when and how to intervene may be variable depending on physicians' interpretation of available data regarding natural history and morbidity and mortality of interventions. Another significant factor in the decision process is the patients' conception of the risks of rupture and interventions and the psychological burden of harboring an unruptured intracranial aneurysm. Objective  To describe which factors are being considered when patients and their physicians decide how to manage unruptured intracranial aneurysms.  Materials & methods  In a retrospective chart review study, we identified patients seen for evaluation of an unruptured intracranial aneurysm. Data was collected regarding patient and aneurysm characteristics. The physician note pertaining to the management decision was reviewed for documented reasons for intervention. Results  Of 88 patients included, 36 (41%) decided to undergo open or endovascular surgery for at least one unruptured intracranial aneurysm. Multiple aneurysms were present in 14 (16%) patients. Younger patients and current smokers were more likely to undergo surgery, but gender and race did not affect management. Aneurysm size and location strongly influenced management. The most common documented reasons underlying the decision of whether to intervene were the risk of rupture, aneurysm size, and risks of the procedure. For 23 aneurysms (21%), there were no factors documented for the management decision.  Conclusion  The risk of rupture of unruptured intracranial aneurysms may be underestimated by currently available natural history data. Major factors weighed by physicians in management decisions include aneurysm size and location, the patient's age, and medical comorbidities along with the risk of procedural complications. Additional data is needed to define specific aneurysm characteristics and patient factors that influence rupture, in particular in small aneurysms. Physicians should carefully document their rationale along with the patient's perspective given the controversial nature of these management decisions.

Variation of T-type calcium channel protein expression affects cell division of cultured tumor cells.

In this study we investigated the T-type calcium channel and its involvement in the cell division of U87MG cultured glioma cells and N1E-115 neuroblastoma cells. Using Western blot analysis, we found that expression of both alpha1G and alpha1H subunits of the T-type calcium channel decreased during conditions associated with a decrease in proliferation as evidenced by increased expression of cyclin D1, a marker for non-proliferating cells. Both serum starvation and application of mibefradil, a selective T-type calcium channel antagonist, resulted in a 50% decrease in the expression of alpha1G and alpha1H and a 700-900% increase in levels of cyclin D1 in U87MG and N1E-115 cells, respectively. Furthermore, overexpression of the alpha1H subunit resulted in a two-fold increase in cell proliferation compared to control cultures or cultures receiving an empty vector. In contrast, blocking expression of the alpha1G subunit using antisense oligonucleotides lead to a 70% decrease in proliferation of U87MG and N1E-115 cells compared to control cultures or cultures receiving a scrambled oligonucleotide. Our findings suggest that proliferation of U87MG glioma cells and N1E-115 is regulated by T-type calcium channel expression.

Management of malignant tumors of the anterior and anterolateral skull base.

OBJECT: Malignant tumors of the skull base represent a group of diverse and infrequent lesions. Comprehensive oncological management requires a multidisciplinary team of neurological surgeons, otolaryngologists, radiation oncologists, plastic surgeons, and medical oncologists. The authors describe an institutional experience in performing 54 combined anterior-anterolateral cranial base resections for malignant disease. METHODS: The technical considerations for preoperative workup, surgical approach, resection, and reconstruction are outlined and illustrated. Considerations for complication management and avoidance are detailed. CONCLUSIONS: Overall mortality (0%) and morbidity rates (18%) are acceptable. The influence on the natural history of the disease process is an ongoing study.

Neurotraumatology.

Neurotraumatology has its roots in ancient history, but its modern foundations are the physical examination, imaging to localize the pathology, and thoughtful medical and surgical decision making. The neurobiology of cranial and spinal injury is similar, with the main goal of therapies being to limit secondary injury. Brain injury treatment focuses on minimizing parenchymal swelling within the confined cranial vault. Spine injury treatment has the additional consideration of spinal coumn stability. Current guidelines for non-operative and operative management are reviewed in this chapter.

Model-based simulation for early neurosurgical learners.

BACKGROUND: Restrictions on duty hours and shift length by the Accreditation Council for Graduate Medical Education and public pressure to reduce complications and to improve outcomes in the clinical educational environment have enhanced interest in the use of procedural and surgical simulation to train neurosurgical residents. OBJECTIVE: To introduce simple, available, and, when possible, inexpensive model-based simulation for early learners into the initial stages of neurosurgical residency training. METHODS: Simulation for early-stage trainees in neurological surgery has taken advantage of model-based systems. The Society of Neurological Surgeons postgraduate year 1 courses have served as one paradigm for designing and using model-based simulators for procedural and surgical skill training as part of a purpose-designed overall curriculum. Ongoing surveys of resident and faculty course participants have supported iterative improvements in simulator models and curriculum from year to year. RESULTS: Simulation for basic neurosurgical and intensive care procedures has been undertaken through the use of available materials, surgical technology, and modifications of related existing model simulators. Simulation of common, standard surgical procedures for early learners may be broken into individual surgical skills and maneuvers to prepare trainees for safe practice of these component skills during live procedures under direct supervision appropriate to their training stage. CONCLUSION: Model-based simulation is particularly effective for early surgical learners as part of a coordinated curriculum. Almost 600 residents have used model-based simulation during the first 3 years of the Society of Neurological Surgeons boot camp courses, with ongoing modification and improvement of individual simulation models.

Society of Neurological Surgeons boot camp courses: knowledge retention and relevance of hands-on learning after 6 months of postgraduate year 1 training.

OBJECT: In July 2010, the Society of Neurological Surgeons (SNS) introduced regional courses to promote patient safety and teach fundamental skills and knowledge to all postgraduate Year 1 (PGY1) trainees entering Accreditation Council for Graduate Medical Education (ACGME)-accredited US neurosurgery residency programs. Data from these courses demonstrated significant didactic learning and high faculty and resident satisfaction with hands-on training. Here, the authors evaluated the durability of learning from and the relevance of participation in SNS PGY1 courses as measured midway through PGY1 training. METHODS: Resident participants were resurveyed 6 months after boot camp course attendance to assess knowledge retention and course effectiveness. Exposure to relevant hands-on experiences during PGY1 training and the subjective value of pre-residency simulated training in the courses were assessed. RESULTS: Ninety-four percent of all residents entering US PGY1 neurosurgical training participated in the 2010 SNS boot camp courses. One hundred sixty-four (88%) of these resident participants responded to the survey. Six months after course completion, 99% of respondents believed the boot camp courses benefited beginning neurosurgery residents and imparted skills and knowledge that would improve patient care. The PGY1 residents' knowledge of information taught in the courses was retained 6 months after initial testing (p < 0.0001). CONCLUSIONS: The learning and other benefits of participation in a national curriculum for residents entering PGY1 neurosurgical training were maintained 6 months after the courses, halfway through the initial training year.

A national fundamentals curriculum for neurosurgery PGY1 residents: the 2010 Society of Neurological Surgeons boot camp courses.

BACKGROUND: In July 2009, the Accreditation Council for Graduate Medical Education (ACGME) incorporated postgraduate year 1 (PGY1 intern) level training into all U.S. neurosurgery residency programs. OBJECTIVE: To provide a fundamentals curriculum for all incoming neurosurgery PGY1 residents in ACGME-accredited programs, including skills, knowledge, and attitudes that promote quality, patient safety, and professionalism. METHODS: The Society of Neurological Surgeons organized 6 regional "boot camp" courses for incoming neurosurgery PGY1 residents in July 2010 that consisted of 9 lectures on clinical and nonclinical competencies plus 10 procedural and 6 surgical skills stations. Resident and faculty participants were surveyed to assess knowledge and course effectiveness. RESULTS: A total of 186 of 197 U.S. neurosurgical PGY1 residents (94%) and 75 neurosurgical faculty from 36 of 99 programs (36%) participated in the inaugural boot camp courses. All residents and 83% of faculty participants completed course surveys. All resident and faculty respondents thought that the boot camp courses fulfilled their purpose and objectives and imparted skills and knowledge that would improve patient care. PGY1 residents' knowledge of information taught in the courses improved significantly in postcourse testing (P < .0001). Residents and faculty particularly valued simulated and other hands-on skills training. CONCLUSION: Regional organization facilitated an unprecedented degree of participation in a national fundamental skills program for entering neurosurgery residents. One hundred percent of resident and faculty respondents positively reviewed the courses. The boot camp courses may provide a model for enhanced learning, professionalism, and safety at the inception of training in other procedural specialties.