More Laboratory Simulations-Fewer Brain Complications: Prospects from the First Neurosurgery Laboratory in Iraq.

BACKGROUND: The intensive training requirements needed to achieve the requisiste microneurosurgical milestones makes proper training and skill acquisition a challenge to the novice neurosurgeon. This problem is compounded in low- and middle-income nations, where neurosurgery is subject to a myriad of human and financial resource constraints. A temporary solution may be provided by low-cost laboratories that are adaptive to local needs. METHODS: The "HOZ NeuroSurgery LAB" is a nonprofit facility dedicated to microneurosurgery education and skills training. The laboratory, established in June 2015, is housed at the Neurosurgery Teaching Hospital in Baghdad, Iraq. It operates under the motto "More Laboratory Simulation-Fewer Brain Complications.". The fundamental infrastructure of the facility consists of a relatively inexpensive microscope, indigenous locally created training equipment, and animal-based models. RESULTS: Since its inception, this lab has functioned as a hub for resident education and microneurosurgery service, in addition to contributing to the specialty's academic output in the nation. The lab is directly responsible for training 4 vascular neurosurgeons who are currently directing the nation's first organized neurovascular service. Also, it has delivered 53 microneurosurgery skills courses, coordinated 8 student neurosurgery elective cycles with a total of 532 participants, and published approximately 70 research articles. CONCLUSIONS: Our experience may serve as a model for other low- and middle-income countries interested in using the principle of "doing more with less" to overcome some of the challenges associated with microneurosurgery in these parts of the world.

Trends in physician reimbursements and procedural volumes for radiosurgery versus open surgery in brain tumor care: an analysis of Medicare data from 2009 to 2018.

OBJECTIVE: Given its minimally invasive nature and effectiveness, stereotactic radiosurgery (SRS) has become a mainstay for the multimodal treatment of intracranial neoplasm. However, no studies have evaluated recent trends in the use of SRS versus those of open resection for the management of brain tumor or trends in the involvement of neurosurgeons in SRS (which is primarily delivered by radiation oncologists). Here, the authors used publicly available Medicare data from 2009 to 2018 to elucidate trends in the treatment of intracranial neoplasm and to compare reimbursements between these approaches. METHODS: By using CPT Professional 2019, the authors identified 10 open resection and 9 SRS codes (4 for neurosurgery and 5 for radiation oncology) for the treatment of intracranial neoplasm. Medicare payments (inflation adjusted) and allowed services (number of reimbursed procedures) for each code were abstracted from the Centers for Medicare and Medicaid Services Part B National Summary Data File (2009-2018). Payments per procedure and procedures per 100,000 Medicare enrollees were analyzed with linear regression and compared with tests for equality of slopes (α = 0.05). The average payment per procedure over the study period was compared by using the 2-tailed Welsh unequal variances t-test, and more granular comparisons were conducted by using ANOVA with post hoc Tukey honestly significant difference (HSD) tests. RESULTS: From 2009 to 2018, the number of SRS treatments per 100,000 Medicare enrollees for intracranial neoplasm increased by 3.97 cases/year (R2 = 0.99, p < 0.001), while comparable open resections decreased by 0.34 cases/year (R2 = 0.85, p < 0.001) (t16 = 7.5, p < 0.001). By 2018, 2.6 times more SRS treatments were performed per 100,000 enrollees than open resections (74.9 vs 28.7 procedures). However, neurosurgeon involvement in SRS treatment declined over the study period, from 23.4% to 11.5% of SRS treatments; simultaneously, the number of lesions treated per session increased from 1.46 to 1.84 (R2 = 0.98, p < 0.001). Overall, physician payments from 2013 to 2018 averaged $1816.08 (95% CI $1788.71-$1843.44) per SRS treatment and $1565.59 (95% CI $1535.83-$1595.34) per open resection (t10 = 15.9, p < 0.001). For neurosurgeons specifically, reimbursements averaged $1566 per open resection, but this decreased to $1031-$1198 per SRS session; comparatively, radiation oncologists were reimbursed even less (average $359-$898) per SRS session (p < 0.05 according to the Tukey HSD test for all comparisons). CONCLUSIONS: Over a decade, the number of open resections for intracranial neoplasm in Medicare enrollees declined slightly, while the number of SRS procedures increased greatly. This latter expansion is largely attributable to radiation oncologists; meanwhile, neurosurgeons have shifted their involvement in SRS toward sessions for the management of multiple lesions.

Neurosurgery Research and Education Foundation funding conversion to National Institutes of Health funding.

OBJECTIVE: The Neurosurgery Research and Education Foundation (NREF) provides research support for in-training and early career neurosurgeon-scientists. To define the impact of this funding, the authors assessed the success of NREF awardees in obtaining subsequent National Institutes of Health (NIH) funding. METHODS: NREF in-training (Research Fellowship [RF] for residents) and early career awards/awardees (Van Wagenen Fellowship [VW] and Young Clinician Investigator [YCI] award for neurosurgery faculty) were analyzed. NIH funding was defined by individual awardees using the NIH Research Portfolio Online Reporting tool (1985-2014). RESULTS: Between 1985 and 2014, 207 unique awardees were supported by 218 NREF awards ($9.84 million [M] in funding), including 117 RF ($6.02 M), 32 VW ($1.68 M), and 69 YCI ($2.65 M) awards. Subspecialty funding included neuro-oncology (79 awards; 36% of RF, VW, and YCI awards), functional (53 awards; 24%), vascular (37 awards; 17%), spine (22 awards; 10%), pediatrics (18 awards; 8%), trauma/critical care (5 awards; 2%), and peripheral nerve (4 awards; 2%). These awardees went on to receive $353.90 M in NIH funding that resulted in an overall NREF/NIH funding ratio of 36.0:1 (in dollars). YCI awardees most frequently obtained later NIH funding (65%; $287.27 M), followed by VW (56%; $41.10 M) and RF (31%; $106.59 M) awardees. YCI awardees had the highest NREF/NIH funding ratio (108.6:1), followed by VW (24.4:1) and RF (17.7:1) awardees. Subspecialty awardees who went on to obtain NIH funding included vascular (19 awardees; 51% of vascular NREF awards), neuro-oncology (40 awardees; 51%), pediatrics (9 awardees; 50%), functional (25 awardees; 47%), peripheral nerve (1 awardees; 25%), trauma/critical care (2 awardees; 20%), and spine (2 awardees; 9%) awardees. Subspecialty NREF/NIH funding ratios were 56.2:1 for vascular, 53.0:1 for neuro-oncology, 47.6:1 for pediatrics, 34.1:1 for functional, 22.2:1 for trauma/critical care, 9.5:1 for peripheral nerve, and 0.4:1 for spine. Individuals with 2 NREF awards achieved a higher NREF/NIH funding ratio (83.3:1) compared to those with 1 award (29.1:1). CONCLUSIONS: In-training and early career NREF grant awardees are an excellent investment, as a significant portion of these awardees go on to obtain NIH funding. Moreover, there is a potent multiplicative impact of NREF funding converted to NIH funding that is related to award type and subspecialty.

Assessing the Cost Burden of Pediatric Neurosurgery in Kaduna, Nigeria.

BACKGROUND: Few studies have evaluated the cost burden borne by neurosurgical patients in the developing world and their potential implications for efficient and effective delivery of care. This study aims to assess the cost associated with obtaining pediatric neurosurgical care in a hospital in Kaduna. METHODS: All patients younger than 15 years who had a neurosurgical operation from July to December 2019 were included in the study. The characteristics of the patients were obtained using a proforma while the cost data were retrieved from the accounts unit of the hospital. The direct cost was obtained from the billing records of the hospital. Indirect cost was obtained using a questionnaire. The data obtained were analyzed using SPSS version 25 for Windows. RESULTS: A total of 27 patients were included in the study with a mean age of 7.2 years and a standard deviation of 4.95 years. The 2 most common procedures done were craniotomy for trauma and ventriculoperitoneal shunt insertion for hydrocephalus. The mean total cost of a neurosurgical procedure was $895.99. Intensive care unit length of stay was found to have a significant influence on the direct cost. The cost of surgery and investigation were the main contributors to the total cost of care with a mean of $618.3 and a standard deviation of $248.67. CONCLUSIONS: The mean cost of pediatric neurosurgical procedures in our setting is $895.99, which is 40.18% of our gross domestic product per capita. The main drivers of cost are the cost of operation, investigations, and intensive care unit length of stay.

Geographic Variation in Costs of Transsphenoidal Pituitary Surgery in the United States.

BACKGROUND: Geographic variations in health care costs have been reported for many surgical specialties. OBJECTIVE: In this study, we sought to describe national and regional costs associated with transsphenoidal pituitary surgery (TPS). METHODS: Data from the Truven-MarketScan 2010-2014 were analyzed. We examined overall total, hospital/facility, physician, and out-of-pocket payments in patients undergoing TPS including technique-specific costs. Mean payments were obtained after risk adjustment for patient-level and system-level confounders and estimated differences across regions. RESULTS: The estimated overall annual burden was $43 million/year in our cohort. The average overall total payment associated with TPS was $35,602.30, hospital/facility payment was $26,980.45, physician payment was $4685.95, and out-of-pocket payment was $2330.78. Overall total and hospital/facility costs were highest in the West and lowest in the South (both P < 0.001), whereas physician reimbursements were highest in the North-east and lowest in the South (P < 0.001). There were no differences in out-of-pocket expenses across regions. On a national level, there were significantly higher overall total and hospital/facility payments associated with endoscopic compared with microscopic procedures (both P < 0.001); there were no significant differences in physician payments or out-of-pocket expenses between techniques. There were also significant within-region cost differences in overall total, hospital/facility, and physician payments in both techniques as well as in out-of-pocket expenses associated with microsurgery. There were no significant regional differences in out-of-pocket expenses associated with endoscopic surgery. CONCLUSIONS: Our results show significant geographic cost disparities associated with TPS. Understanding factors behind disparate costs is important for developing cost containment strategies.

Managing Craniomaxillofacial Injury Without Inpatient Consult: Outcomes and Patient Cost Savings.

BACKGROUND: We hypothesized that trauma surgeons can safely selectively manage traumatic craniomaxillofacial injuries (CMF) without specialist consult, thereby decreasing the overall cost burden to patients. METHODS: A 4-year retrospective analysis of all CMF fractures diagnosed on facial CT scans. CMF consultation was compared with no-CMF consultation. Demographics, injury severity, and specialty consultation charges were recorded. Penetrating injuries, skull fractures, or patients completing inpatient craniofacial surgery were excluded. RESULTS: 303 patients were studied (124 CMF consultation vs 179 no-CMF consultation), mean age was 47.8 years, with 70% males. Mean Glasgow Coma Scale and Injury Severity Score (ISS) was 14 ± 3.4 and 10 ± 9, respectively. Patients with CMF consults had higher ISS (P < .001) and needed surgery on admission (P < .001), while no-CMF consults had shorter length of stay (P < .002). No in-hospital mortality or 30-day readmission rates were related to no-CMF consult. Total patient charges saved with no-CMF consultation was $26 539.96. DISCUSSION: Trauma surgeons can selectively manage acute CMF injuries without inpatient specialist consultation. Additional guidelines can be established to avoid tertiary transfers for specialty consultation and decrease patient charges.

Early Career Challenges in Setting Up an Endoscopic Spine Surgery Practice.

After the completion of an endoscopic spinal surgery fellowship, the next challenge for the newly minted consultant is to set up a viable and sustainable endoscopic practice. A successful practice of endoscopic spine surgery is dependent on several factors, such as anesthetic support; surgical expertise; support for provision and maintenance of endoscopic equipment; cost of equipment; administrative and nursing support; postoperative care services to optimize patients' outcome and satisfaction; patients' ideas, concerns, and expectations, as well as continuing medical education. In this article, a perspective is given on the early career challenges that a fellowship-trained endoscopic surgeon may encounter in the period leading to first successful endoscopic spinal surgery.

Afternoon Surgical Start Time Is Associated with Higher Cost and Longer Length of Stay in Posterior Lumbar Fusion.

BACKGROUND: Existing research about surgical start time is equivocal about associations between outcomes and late start times, and there is only one published report investigating start time in spine surgery. Therefore, the objective of this study was to assess associations between surgical start time, length of stay (LOS), and cost in lumbar spine surgery. METHODS: Patients at a single institution undergoing posterior lumbar fusion (PLF) were grouped based on whether they received their surgery before or after 2 pm, with those receiving their surgery between 12 am and 6 am and receiving surgery for tumors, trauma, or infections being excluded. These 2 groups were then compared on the basis of demographics and outcomes with cost and LOS as the coprimary outcomes. RESULTS: A total of 2977 patients underwent PLF during the study period. There were minimal differences in preoperative characteristics of the cohorts. The patients who underwent PLF starting after 2 pm had longer LOS (0.45 days; 95% confidence interval [CI], 0.18-0.72; P = 0.001) and higher costs ($1343; 95% CI, $339-$2348; P = 0.009) than cases starting before 2 pm The late surgical start cohort also had higher rates of nonhome discharge (29.73% vs. 23.17%, P = 0.0004), and 30-day (4.36% vs. 2.5%, P = 0.01) and 90-day emergency department visits (5.72% vs. 2.94%, P = 0.0005). CONCLUSIONS: Late surgical start time is associated with longer LOS and higher cost in patients undergoing PLF.

Emerging Trends in the Neurosurgical Workforce of Low- and Middle-Income Countries: A Cross-Sectional Study.

BACKGROUND: Every year, there are an estimated 22.6 million new neurosurgical consultative cases worldwide, of which 13.8 million require surgery. In 2016, the global neurosurgical workforce was estimated and mapped as open-access information to guide neurosurgeons, affiliates, and policy makers. We present a subsequent investigation for mapping the global neurosurgical workforce for 2018 to show the replicability of previous data collection methods as well as to show any changes in workforce density. METHODS: We extracted data on the absolute number of neurosurgeons per low and middle-income countries (LMICs) in 2016 from the database of the global neurosurgical workforce mapping project. The estimated number of neurosurgeons in each LMIC during 2018 was obtained from collaborators. The median workforce densities were calculated for 2016 and 2018. Neurosurgical workforce density heat maps were generated. RESULTS: We received data from 119 countries (response rate 86.2%) and imputed data for 19 countries (13.8%). Seventy-eight (56.5%, N = 138) countries had an increase in their number of neurosurgeons, 9 (6.5%) showed a decrease, whereas 51 (37.0%) had the same number of neurosurgeons in both years. The pooled median increased from 0.17 (interquartile range, 0.54) in 2016 to 0.18 (interquartile range, 0.59) in 2018. CONCLUSIONS: Overall, the density of the neurosurgical workforce has increased from 2016 to 2018. However, at the current rate, 80 LMICs (58.0%) will not meet the neurosurgical workforce density target by 2030.

Developing a Guideline for Neurotrauma in Nigeria.

BACKGROUND: The Nigerian Academy of Neurological Surgeons in 2019 resolved to standardize the practice of neurosurgery in Nigeria. It set up committees to standardize the various aspects of neurosurgery, such as neurotrauma, pediatrics, functional, vascular, skull base, brain tumor, and spine. The Committee on Neurotrauma convened and resolved to study most of the available protocols and guidelines in use in different parts of the world. OBJECTIVE: To formulate a standard protocol for the practice of neurotrauma care within the Nigerian locality. METHODS: The Committee split its membership into 3 subcommittees to cover the various aspects of the Neurotrauma Guidelines, such as neurotrauma curriculum, standard neurotrauma management protocols, and neurotrauma registry. Each subcommittee was to research on available models and formulate a draft for Nigerian neurotrauma. RESULTS: All the 3 subcommittees had their reports ready on schedule. Each concurred that neurotrauma is a major public health challenge in Nigeria. They produced 3 different drafts on the 3 thematic areas of the project. The subcommittees are: 1. Subcommittee on Fellowship, Training and Research Curriculum; 2. Subcommittee on Standard Protocols and Management Guidelines; and 3. Subcommittee of the Nigerian Neurotrauma Registry. CONCLUSION: The committee concluded that a formal protocol for neurotrauma care is long overdue in Nigeria for the standardization of all aspects of neurotrauma. It then recommended the adoption of these guidelines by all institutions offering services in Nigeria using the management protocols, opening a registry, and mounting researches on the various aspects of neurotrauma.

Impact of robot-assisted spine surgery on health care quality and neurosurgical economics: A systemic review.

Whenever any new technology is introduced into the healthcare system, it should satisfy all three pillars of the iron triangle of health care, which are quality, cost-effectiveness, and accessibility. There has been quite advancement in the field of spine surgery in the last two decades with introduction of new technological modalities such as CAN and surgical robotic devices. MAZOR SpineAssist/Renaissance was the first robotic system to be approved for the use in spine surgeries in the USA in 2004. In this review, the authors sought to determine if the current literature supports this technology to be cost-effective, accessible, and improve the quality of care for individuals and populations by increasing the likelihood of desired health outcomes. Robotic-assisted surgery seems to provide perfection in surgical ergonomics and surgical dexterity, consequently improving patient outcomes. A lot of data is present on the accuracy, effectiveness, and safety of the robotic-guided technology which reflects remarkable improvements in quality of care, making its utility convincingly undisputable. The technology has been claimed to be cost-effective but there seems to be lack of data in the literature on this topic to validate this claim. Apart from just the outcome parameters, there is an immense need of studies on real-time cost-efficacy, patient perspective, surgeon and resident learning curve, and their experience with this new technology. Furthermore, new studies looking into increased utilities of this technology, such as brain and spine tumor resection, deep brain stimulation procedures, and osteotomies in deformity surgery, might authenticate the cost of the equipment.

Worldwide Access to Stereotactic Radiosurgery.

Stereotactic radiosurgery is a safe and effective technology that can address a variety of neurosurgical conditions, but in many parts of the world, access remains an issue. Although the technology is increasingly available in the United States, Canada, Europe, and parts of Asia, poor access to central nervous system (CNS) imaging and inadequate treatment equipment in other parts of the world limit the availability of radiosurgery as a treatment option. In addition, epidemiologic data about cancer and CNS metastases in low-income countries are sparse and much less complete than in more developed countries, and the need for radiosurgery may be underestimated as a result. Current radiosurgical platforms can be expensive to install and require a substantial amount of personnel training for safe operation. Socioeconomic and political forces are relevant to limitations to and opportunities for improving access to care. Here we examine the current barriers to access and propose areas for future efforts to improve global availability of radiosurgery for neurosurgical conditions.

Snapshot: Socioeconomic Competence in US Neurosurgery Residents.

INTRODUCTION: Socioeconomic topics such as federal mandates/regulations, conflict of interest, and practice management have become increasingly important for all neurosurgeons. Graduating residents immediately need a host of skills to successfully navigate neurosurgical practice. Surgical and medical skills are closely evaluated through the American Board of Neurological Surgery, and a formal socioeconomic curriculum has been developed with defined milestones. Nevertheless, little has been done to evaluate neurosurgery resident competence in socioeconomic and medicolegal principles. The purpose of this study was to assess the competence of Accreditation Council for Graduate Medical Education neurosurgical residents in socioeconomic knowledge. METHODS: Neurosurgery resident members of the American Association of Neurological Surgeons (N = 1385) were sent a Survey Monkey of 10 questions. The survey covered the most basic of socioeconomic principles. Initial survey responses were collected across a 1-month period from April to May 2018. RESULTS: The response rate was 14% (194/1385). Overall, neurosurgery residents would have received a grade of D, with an average score of 67% on the survey. For 7 of the 10 questions, the majority (>50%) of neurosurgery residents answered correctly. Furthermore, for 3 questions, more than 90% of residents selected the correct answer. However, for one-half of all questions, residents averaged a score of less than 65%. Residents tended to answer questions correctly for physician compensation and compensation models, but incorrectly for topics of informed consent, Controlled Substances Act, and conflicts of interest. CONCLUSION: With the increasing complexity of neurosurgery practice, solid knowledge of socioeconomic topics is essential. The study confirms suspected deficiencies in socioeconomic proficiency among neurosurgery residents, despite the availability of a validated curriculum. This knowledge gap will likely affect career success and satisfaction. Nevertheless, this survey had a significantly low response rate, and it may be an incomplete representation of the neurosurgical resident mind. Focused educational initiatives through the neurosurgical Residency Review Committee and individual training programs must facilitate an action plan that ensures the effective implementation of socioeconomic curricula.

Financial Implications of Physician Specialty Choice.

PURPOSE: To examine the approximated financial outcomes of physicians by specialty and to determine whether these correlate with mean USMLE Step 1 scores. METHODS: Specialty-specific data from the Association of American Medical Colleges Careers in Medicine website were analyzed for total length of training, mean USMLE Step 1 scores, average hours worked per week, and median clinical practice salary for physicians. Hourly wage and estimated net worth at retirement were calculated. Coefficients of determination (R2) were calculated to evaluate the relationships between hourly wage, annual salary, and estimated net worth at retirement with competitiveness as measured by USMLE Step 1 scores of matched residents. RESULTS: Across all 37 specialties studied, the mean hourly wage was $136 ± $40, ranging from $78 (Geriatrics) to $249 (Neurosurgery). Mean weekly hours worked across all specialties was 54.6 ± 6.4, ranging from 43.4 (Pediatric Emergency Medicine) to 71.1 (Vascular Surgery). At retirement, the mean estimated net worth for all physicians was $4,517,600 ± $1,793,095, ranging from $1,927,779 (Child & Adolescent Psychiatry) to $8,947,885 (Neurosurgery). Step 1 scores, as a marker of specialty competiveness, correlate with specialty compensation - the strongest association was with hourly wage (R2 = 0.6678), then annual salary (R2 = 0.6424), and finally by estimated net worth at retirement (R2 = 0.6158). CONCLUSION: In this study, mean Step 1 scores for each medical specialty were positively correlated with compensation, including absolute salary, hourly wage and estimated net worth at retirement.

Neurosurgery and Sustainable Development Goals.

BACKGROUND: On September 25, 2015, the United Nations General Assembly adopted a 17-goal action plan to transform the world by the year 2030, ushering in the Era of Sustainable Development. These Sustainable Development Goals (SDGs) were designed to continue where the preceding Millennium Development Goals left off, expanding on the Millennium Development Goal successes, and facing the challenges encountered during the previous decade and a half. The current Era of Sustainable Development and its impact on a breadth of neurosurgical concerns provide several unprecedented opportunities to enhance political prioritization of neurosurgical care equity. Neurosurgeons could therefore be well positioned to participate in the leadership of these global health development and policy reform efforts. METHODS: Each of the 17 SDGs was reviewed and analyzed for its relevance to the public health aspects of neurosurgery. The analysis was guided by a review of the literature performed in PubMed, Google Scholar, and the databases of the World Health Organization. RESULTS: Among the 17 SDGs, 14 were found to be of direct or indirect relevance to neurosurgeons and neurosurgical care delivery. Results of this analysis are presented and discussed, and recommendations are provided for using this knowledge to inform the emerging discipline of global neurosurgery. CONCLUSIONS: This article contributes to the global neurosurgery movement by providing the socially and globally conscious neurosurgeon with a compass for directing the place of neurosurgery in the international agenda for sustainable development.

Magnetic Resonance-Guided Focused Ultrasound Neurosurgery for Essential Tremor: A Health Technology Assessment.

BACKGROUND: The standard treatment option for medication-refractory essential tremor is invasive neurosurgery. A new, noninvasive alternative is magnetic resonance-guided focused ultrasound (MRgFUS) neurosurgery. We aimed to determine the effectiveness, safety, and cost-effectiveness of MRgFUS neurosurgery for the treatment of moderate to severe, medication-refractory essential tremor in Ontario. We also spoke with people with essential tremor to gain an understanding of their experiences and thoughts regarding treatment options, including MRgFUS neurosurgery. METHODS: We performed a systematic review of the clinical literature published up to April 11, 2017, that examined MRgFUS neurosurgery alone or compared with other interventions for the treatment of moderate to severe, medication-refractory essential tremor. We assessed the risk of bias of each study and the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. We performed a systematic review of the economic literature and created Markov cohort models to assess the cost-effectiveness of MRgFUS neurosurgery compared with other treatment options, including no surgery. We also estimated the budget impact of publicly funding MRgFUS neurosurgery in Ontario for the next 5 years. To contextualize the potential value of MRgFUS neurosurgery as a treatment option for essential tremor, we spoke with people with essential tremor and their families. RESULTS: Nine studies met our inclusion criteria for the clinical evidence review. In noncomparative studies, MRgFUS neurosurgery was found to significantly improve tremor severity and quality of life and to significantly reduce functional disability (GRADE: very low). It was also found to be significantly more effective than a sham procedure (GRADE: high). We found no significant difference in improvements in tremor severity, functional disability, or quality of life between MRgFUS neurosurgery and deep brain stimulation (GRADE: very low). We found no significant difference in improvement in tremor severity compared with radiofrequency thalamotomy (GRADE: low). MRgFUS neurosurgery has a favourable safety profile.We estimated that MRgFUS neurosurgery has a mean cost of $23,507 and a mean quality-adjusted survival of 3.69 quality-adjusted life-years (QALYs). We also estimated that the mean costs and QALYs of radiofrequency thalamotomy and deep brain stimulation are $14,978 and 3.61 QALYs, and $57,535 and 3.94 QALYs, respectively. For people ineligible for invasive neurosurgery, we estimated the incremental cost-effectiveness ratio (ICER) of MRgFUS neurosurgery compared with no surgery as $43,075 per QALY gained. In people eligible for invasive neurosurgery, the ICER of MRgFUS neurosurgery compared with radiofrequency thalamotomy is $109,795 per QALY gained; when deep brain stimulation is compared with MRgFUS neurosurgery, the ICER is $134,259 per QALY gained. Of note however, radiofrequency thalamotomy is performed very infrequently in Ontario. We also estimated that the budget impact of publicly funding MRgFUS neurosurgery in Ontario at the current case load (i.e., 48 cases/year) would be about $1 million per year for the next 5 years.People with essential tremor who had undergone MRgFUS neurosurgery reported positive experiences with the procedure. The tremor reduction they experienced improved their ability to perform activities of daily living and improved their quality of life. CONCLUSIONS: MRgFUS neurosurgery is an effective and generally safe treatment option for moderate to severe, medication-refractory essential tremor. It provides a treatment option for people ineligible for invasive neurosurgery and offers a noninvasive option for all people considering neurosurgery.For people ineligible for invasive neurosurgery, MRgFUS neurosurgery is cost-effective compared with no surgery. In people eligible for invasive neurosurgery, MRgFUS neurosurgery may be one of several reasonable options. Publicly funding MRgFUS neurosurgery for the treatment of moderate to severe, medication-refractory essential tremor in Ontario at the current case load would have a net budget impact of about $1 million per year for the next 5 years.People with essential tremor who had undergone MRgFUS neurosurgery reported positive experiences. They liked that it was a noninvasive procedure and reported a substantial reduction in tremor that resulted in an improvement in their quality of life.

The Growth of Neurosurgery in East Africa: Challenges.

As the second of 3 articles in this series, the aim of this article is to provide readers with an understanding of the development of neurosurgery in East Africa (foundations), the challenges that arise in providing neurosurgical care in developing countries (challenges), and an overview of traditional and novel approaches to overcoming these challenges and improving health care in the region (innovations). Recognizing the challenges that need to be addressed is the first step to implementing efficient and qualified surgery delivery systems in low- and middle-income countries. We reviewed the major challenges facing health care in East Africa and grouped them into 5 categories: 1) burden of surgical disease and workforce crisis; 2) global health view of surgery as "the neglected stepchild"; 3) need for recognizing the surgical system as an interdependent network and importance of organizational and equipment deficits; 4) lack of education in the community, failure of primary care systems, and net result of overwhelming tertiary care systems; 5) personal and professional burnout as well as brain drain of promising human resources from low- and middle-income countries in East Africa and similar regions across the world. Each major challenge was detailed and analyzed by authors who have worked or are currently working in the region, providing a personal perspective.

Industry Financial Relationships in Neurosurgery in 2015: Analysis of the Sunshine Act Open Payments Database.

OBJECTIVE: The 2013 Physician Payments Sunshine Act mandates that all U.S. drug and device manufacturers disclose payments to physicians. All payments are made available annually in the Open Payments Database (OPD). Our aim was to determine prevalence, magnitude, and nature of these payments to physicians performing neurologic surgery in 2015 and to discuss the role that financial conflicts of interest play in neurosurgery. METHODS: All records of industry financial relationships with physicians identified by the neurological surgery taxonomy code in 2015 were accessed via the OPD. Data were analyzed in terms of type and amounts of payments, companies making payments, and comparison with previous studies. RESULTS: In 2015, 83,690 payments (totaling $99,048,607) were made to 7613 physicians by 330 companies. Of these, 0.01% were >$1 million, and 73.2% were <$100. The mean payment ($13,010) was substantially greater than the median ($114). Royalties and licensing accounted for the largest monetary value of payments (74.2%) but only 1.7% of the total number. Food and beverage payments were the most commonly reported transaction (75%) but accounted for only 2.5% of total reported monetary value. Neurologic surgery had the second highest average total payment per physician of any specialty. CONCLUSIONS: The neurological surgery specialty receives substantial annual payments from industry in the United States. The overall value is driven by a small number of payments of high monetary value. The OPD provides a unique opportunity for increased transparency in industry-physician relationships facilitating disclosure of financial conflicts of interest.

A microcontroller-based simulation of dural venous sinus injury for neurosurgical training.

OBJECTIVE Surgical simulation has the potential to supplement and enhance traditional resident training. However, the high cost of equipment and limited number of available scenarios have inhibited wider integration of simulation in neurosurgical education. In this study the authors provide initial validation of a novel, low-cost simulation platform that recreates the stress of surgery using a combination of hands-on, model-based, and computer elements. Trainee skill was quantified using multiple time and performance measures. The simulation was initially validated using trainees at the start of their intern year. METHODS The simulation recreates intraoperative superior sagittal sinus injury complicated by air embolism. The simulator model consists of 2 components: a reusable base and a disposable craniotomy pack. The simulator software is flexible and modular to allow adjustments in difficulty or the creation of entirely new clinical scenarios. The reusable simulator base incorporates a powerful microcomputer and multiple sensors and actuators to provide continuous feedback to the software controller, which in turn adjusts both the screen output and physical elements of the model. The disposable craniotomy pack incorporates 3D-printed sections of model skull and brain, as well as artificial dura that incorporates a model sagittal sinus. RESULTS Twelve participants at the 2015 Western Region Society of Neurological Surgeons postgraduate year 1 resident course ("boot camp") provided informed consent and enrolled in a study testing the prototype device. Each trainee was required to successfully create a bilateral parasagittal craniotomy, repair a dural sinus tear, and recognize and correct an air embolus. Participant stress was measured using a heart rate wrist monitor. After participation, each resident completed a 13-question categorical survey. CONCLUSIONS All trainee participants experienced tachycardia during the simulation, although the point in the simulation at which they experienced tachycardia varied. Survey results indicated that participants agreed the simulation was realistic, created stress, and was a useful tool in training neurosurgical residents. This simulator represents a novel, low-cost approach for hands-on training that effectively teaches and tests residents without risk of patient injury.