On the balance beam: facing the challenges of neurosurgical education in the third millennium.

Background: Neurosurgery is one of the most complex and challenging areas of medicine, and it requires an ongoing commitment to education and expertise. Preparing young neurosurgeons with comprehensive education that can allow them to achieve high professional standards is a pivotal aspect of our profession. Methods: This paper aims to analyze the current scenario in neurosurgical training identifying innovative methods that can guarantee the highest level of proficiency in our specialty. Results: Given the inherent high-stakes nature of neurosurgical procedures, there is a significant burden of responsibility in ensuring that neurosurgical training is of the highest caliber, capable of producing practitioners who possess not just theoretical knowledge but also practical skills and well-tuned judgment. Conclusion: Providing high-quality training is one of the major challenges that the neurosurgical community has to face nowadays, especially in low- and middle-income countries; one of the main issues to implementing neurosurgery worldwide is that the majority of African countries and many areas in Southeast Asia still have few neurosurgeons who encounter enormous daily difficulties to guarantee the appropriate neurosurgical care to their population.

The importance of social networks in neurosurgery training in low/middle income countries.

Introduction: Neurosurgery is evolving with new techniques and technologies, relies heavily on high-quality education and training. Social networks like Twitter, Facebook, Instagram and LinkedIn have become integral to this training. These platforms enable sharing of surgical experiences, fostering global knowledge-sharing and collaboration among neurosurgeons. Virtual conferences and courses are accessible, enhancing learning regardless of location. While these networks offer real-time communication and collaborative opportunities, they also pose challenges like the spread of misinformation and potential distractions. According to the PICO format, the target population (P) for the purpose of this paper are medical students, neurosurgical residents and consultants on the role of social media (I) in neurosurgery among Low-Middle income countries (C) with the main outcome to understand the collaborative domain of learning. Material and method: This cross-sectional survey, conducted in June-July 2023, involved 210 medical students, neurosurgery residents, fellows, and practicing neurosurgeons from low and middle-income countries. A structured questionnaire assessed social network usage for neurosurgery training, covering demographic details, usage frequency, and purposes like education, collaboration, and communication. Participants rated these platforms' effectiveness in training on a 1-5 scale. Data collection employed emails, social media groups, and direct messaging, assuring respondent anonymity. The survey aimed to understand and improve social networks' use in neurosurgery, focusing on professional development, challenges, and future potential in training. Results: In a survey of 210 participants from low and middle-income countries, 85.5% were male, 14.5% female, with diverse roles: 42.9% neurosurgery residents, 40% practicing neurosurgeons, 14.6% medical students, and 2.4% other healthcare professionals. Experience ranged from 0 to 35 years, with Mexico, Nigeria, and Kenya being the top participating countries. Most respondents rated neurosurgery training resources in their countries as poor or very poor. 88.7% used social media professionally, predominantly WhatsApp and YouTube. Content focused on surgical videos, research papers, and webinars. Concerns included information quality and data privacy. Interactive case discussions, webinars, and lectures were preferred resources, and most see a future role for social media in neurosurgery training. Conclusions: Our study underscores the crucial role of social media in neurosurgery training and practice in low and middle-income countries (LMICs). Key resources include surgical videos, research papers, and webinars. While social media offers a cost-effective, global knowledge-sharing platform, challenges like limited internet access, digital literacy, and misinformation risks remain significant in these regions.

Early management of adult traumatic spinal cord injury in patients with polytrauma: a consensus and clinical recommendations jointly developed by the World Society of Emergency Surgery (WSES) & the European Association of Neurosurgical Societies (EANS).

BACKGROUND: The early management of polytrauma patients with traumatic spinal cord injury (tSCI) is a major challenge. Sparse data is available to provide optimal care in this scenario and worldwide variability in clinical practice has been documented in recent studies. METHODS: A multidisciplinary consensus panel of physicians selected for their established clinical and scientific expertise in the acute management of tSCI polytrauma patients with different specializations was established. The World Society of Emergency Surgery (WSES) and the European Association of Neurosurgical Societies (EANS) endorsed the consensus, and a modified Delphi approach was adopted. RESULTS: A total of 17 statements were proposed and discussed. A consensus was reached generating 17 recommendations (16 strong and 1 weak). CONCLUSIONS: This consensus provides practical recommendations to support a clinician's decision making in the management of tSCI polytrauma patients.

Spinal dural cerebrospinal fluid fistula as a cause of spontaneous intracranial hypotension syndrome: Diagnosis and surgical treatment.

Spontaneous intracranial hypotension (SIH) syndrome most often occurs following a cerebrospinal fluid (CSF) fistula that develops in the spinal space. Neurologists and neurosurgeons lack an understanding of the pathophysiology and diagnosis of this disease, which can make timely surgical care difficult. With the correct diagnostic algorithm, it is possible to identify the exact location of the liquor fistula in 90% of cases; subsequent microsurgical treatment can save the patient from the symptoms of intracranial hypotension and restore the ability to work. Female patient, 57 years old, was admitted with SIH syndrome. Magnetic resonance imaging (MRI) of the brain with contrast confirmed signs of intracranial hypotension. Computed tomography (CT) myelography was performed to pinpoint the location of the CSF fistula. The diagnostic algorithm and successful microsurgical treatment of a patient with spinal dural CSF fistula at the Th3-4 level using a posterolateral transdural approach. The patient was discharged on day 3 after the surgery when these complaints regressed completely. At the control examination of the patient 4 months postoperatively, there were no complaints. Identification of the cause and location of spinal the CSF fistula is a complex process that requires several stages of diagnosis. Examination of the entire back with MRI, CT myelography, or subtraction dynamic myelography is recommended. Microsurgical repair of a spinal fistula is an effective method for the treatment of SIH. The posterolateral transdural approach is effective in the repair of a spinal CSF fistula located ventrally in the thoracic spine.

Data Quality Estimation Via Model Performance: Machine Learning as a Validation Tool.

In our recent study, the attempt to classify neurosurgical operative reports into routinely used expert-derived classes exhibited an F-score not exceeding 0.74. This study aimed to test how improving the classifier (target variable) affected the short text classification with deep learning on real-world data. We redesigned the target variable based on three strict principles when applicable: pathology, localization, and manipulation type. The deep learning significantly improved with the best result of operative report classification into 13 classes (accuracy = 0.995, F1 = 0.990). Reasonable text classification with machine learning should be a two-way process: the model performance must be ensured by the unambiguous textual representation reflected in corresponding target variables. At the same time, the validity of human-generated codification can be inspected via machine learning.

Surgical Treatment Efficacy of CSF-Venous Fistulas: Systematic Review.

BACKGROUND: Cerebrospinal fluid (CSF)-venous fistula presents a pathologic connection between spinal subarachnoid space and adjacent epidural vein or veins. It is one of the 3 main causes of spontaneous intracranial hypotension along with dural defects and meningeal diverticulum. We performed a systematic review of the literature and analyzed individual participants' data focusing on clinical outcomes after different treatment modalities of CSF-venous fistula. METHODS: Systematic review was conducted according to PRISMA recommendations. Literature search was performed in PubMed and Web of Science databases with following key phrases: "CSF-venous fistula", "Spontaneous intracranial hypotension". Overall, 97 articles were found during the initial search; 15 were included for the final analysis, with a total number of 137 patients. RESULTS: Epidural blood patch (EBP) was performed as a first-line treatment in 37.1% of patients in individual data group, often not combined with fibrin glue (61.5%). Either partial (69.2%) or no resolution (30.8%) of symptoms was achieved after EBP injection. Nerve root ligation was the most common method of exclusion of CSF-venous fistula. Complete resolution of symptoms was achieved in 69.0% of patients, in 21.4% it was partial and in 9.5% no regress was found. Endovascular treatment was described only in 1 study. CONCLUSIONS: Surgical ligation of fistula is a treatment of choice. In approximately 70% of patients complete long-term resolution of symptoms is achieved after surgery. Endovascular treatment and fibrin glue injections are prospective and evolving options, which require further investigation.

Transcriptomic Portraits and Molecular Pathway Activation Features of Adult Spinal Intramedullary Astrocytomas.

In this study, we report 31 spinal intramedullary astrocytoma (SIA) RNA sequencing (RNA-seq) profiles for 25 adult patients with documented clinical annotations. To our knowledge, this is the first clinically annotated RNA-seq dataset of spinal astrocytomas derived from the intradural intramedullary compartment. We compared these tumor profiles with the previous healthy central nervous system (CNS) RNA-seq data for spinal cord and brain and identified SIA-specific gene sets and molecular pathways. Our findings suggest a trend for SIA-upregulated pathways governing interactions with the immune cells and downregulated pathways for the neuronal functioning in the context of normal CNS activity. In two patient tumor biosamples, we identified diagnostic KIAA1549-BRAF fusion oncogenes, and we also found 16 new SIA-associated fusion transcripts. In addition, we bioinformatically simulated activities of targeted cancer drugs in SIA samples and predicted that several tyrosine kinase inhibitory drugs and thalidomide analogs could be potentially effective as second-line treatment agents to aid in the prevention of SIA recurrence and progression.

Minimally Invasive Resection of a Gangliocytic Paraganglioma of the Cauda Equina: A Case Report and Review of Literature.

Gangliocytic paraganglioma (GP) is considered a rare neuroendocrine tumor (NET) most often located in the distal half of the duodenum. Insufficient reports describe tumors of this histological type located in the distal parts of the spinal canal, the conus medullaris and cauda equina. To date, nine cases of GP of the cauda equina and one case of GP of conus medullaris have been described. After analyzing all available treatment reports of GP, a study described it as a tumor with an extremely good prognosis in cases of total tumor removal. Here, we present a case of a female patient with a GP at the level of the L4 vertebra treated at Burdenko Neurosurgical Center using a minimally invasive approach through a tubular retractor. The tumor was removed en bloc through an intralaminar opening, and the patient was discharged two days after surgery with total regression of symptoms.

Multinomial Classification of Neurosurgical Operations Using Gradient Boosting and Deep Learning Algorithms.

This study aimed at testing the feasibility of neurosurgical procedures classification into 100+ classes using natural language processing and machine learning. A catboost algorithm and bidirectional recurrent neural network with a gated recurrent unit showed almost the same accuracy of ∼81%, with suggestions of correct class in top 2-3 scored classes up to 98.9%. The classification of neurosurgical procedures via machine learning appears to be a technically solvable task which can be additionally improved considering data enhancement and classes verification.

A Comparison of Word Embeddings to Study Complications in Neurosurgery.

Our study aimed to compare the capability of different word embeddings to capture the semantic similarity of clinical concepts related to complications in neurosurgery at the level of medical experts. Eighty-four sets of word embeddings (based on Word2vec, GloVe, FastText, PMI, and BERT algorithms) were benchmarked in a clustering task. FastText model showed the best close to the medical expertise capability to group medical terms by their meaning (adjusted Rand index = 0.682). Word embedding models can accurately reflect clinical concepts' semantic and linguistic similarities, promising their robust usage in medical domain-specific NLP tasks.

Plasma Cytokines Level and Spinal Cord MRI Predict Clinical Outcome in a Rat Glial Scar Cryoinjury Model.

Traumatic injury of the spinal cord is still one of the most challenging problems in the neurosurgical practice. Despite a long history of implementation of translational medicine in the field of spinal cord injury (SCI), it remains one of the most frequent causes of human disability and a critical situation for world healthcare systems. Here, we used our rat model of the of unilateral controlled SCI induced by a cryoinjury, which consistently reproduces glial scarring and posttraumatic cyst formation, and specifically evaluated histological, bioimaging and cytokine data. We propose a 10-grade scoring scale, which can objectively estimate the extent of damage of the experimental SCI according to the magnetic resonance imaging (MRI) results. It provides a homogeneous and reliable visual control of the dynamics of the posttraumatic processes, which makes it possible to clearly distinguish the extent of early damage, the formation of glial scars and the development of posttraumatic syringomyelic cysts. The concentration of cytokines and chemokines in the plasma following the experimental SCI increased up to two orders of magnitude in comparison with intact animals, suggesting that a traumatic injury of the spinal cord was accompanied by a remarkable cytokine storm. Our data suggested that the levels of IL-1α, IL-1ß, TNFα, GRO/KC, G-CSF, IFNγ and IL-13 may be considered as a reliable prognostic index for SCI. Finally, we demonstrated that MRI together with plasma cytokines level directly correlated and reliably predicted the clinical outcome following SCI. The present study brings novel noninvasive and intravital methods for the evaluation of the therapeutic efficacy of SCI treatment protocols, which may be easily translated into the clinical practice.

Spinal Subdural Abscess Mimicking an Extradural Tumor: A Case Report.

Spinal subdural abscesses (SSAs) are rare pathologies presenting as encapsulated pus located intradurally and extramedullary. Although there is no uniform opinion on the cause of this pathology, approximately 50% of cases are attributed to Staphylococcus aureus infection. Here, we present a rare case of a female patient who presented to N.N. Burdenko Neurosurgical Center for treatment of an extradural tumor in the lower lumbar spine. She complained of acute lower back pain, lower limb muscle spasms, progressive lower limb weakness, numbness in toes, and increased frequency of defecation (five to six times per day). Intraoperatively, we discovered that the epidural space was clear and a subdural abscess was located and removed. The patient was started on antibiotics and recovered 29 days later. This case report illustrates an atypical SSA mimicking an extramedullary tumor on MRI.

Best Research Practice Implementation: The Experience of the N.N. Burdenko National Medical Research Center of Neurosurgery.

Implementing the best research principles initiates an important shift in clinical research culture, improving efficiency and the level of evidence obtained. In this article, we share our own view on the best research practice and our experience introducing it into the scientific activities of the N.N. Burdenko National Medical Research Center of Neurosurgery (Moscow, Russian Federation). While being adherent to the principles described in the article, the percentage of publications in the international scientific journals in our Center has increased from 7% to 27%, with an overall gain in the number of articles by 2 times since 2014. We believe it is important that medical informatics professionals equally to medical experts involved in clinical research are familiar with the best research principles.

A New Precision Minimally Invasive Method of Glial Scar Simulation in the Rat Spinal Cord Using Cryoapplication.

According to the World Health Organization, every year worldwide up to 500,000 people suffer a spinal cord injury (SCI). Various animal biomodels are essential for searching for novel protocols and therapeutic approaches for SCI treatment. We have developed an original model of post-traumatic spinal cord glial scarring in rats through cryoapplication. With this method the low-temperature liquid nitrogen is used for the cryodestruction of the spinal cord tissue. Forty-five Sprague Dawley (SD) non-linear male rats of the Specific-pathogen-free (SPF) category were included in this experimental study. A Th13 unilateral hemilaminectomy was performed with dental burr using an operating microscope. A specifically designed cryogenic probe was applied to the spinal cord for one minute through the created bone defect. The animals were euthanized at different time points ranging from 1 to 60 days after cold-induced injury. Their Th12-L1 vertebrae with the injured spinal cord region were removed "en bloc" for histological examination. Our data demonstrate that cryoapplication producing a topical cooling around-20°C, caused a highly standardized transmural lesion of the spinal cord in the dorsoventral direction. The lesion had an "hour-glass" shape on histological sections. During the entire study period (days 1-60 of the post-trauma period), the necrotic processes and the development of the glial scar (lesion evolution) were contained in the surgically approached vertebral space (Th13). Unlike other known experimental methods of SCI simulation (compression, contusion, etc.), the proposed technique is characterized by minimal invasiveness, high precision, and reproducibility. Also, histological findings, lesion size, and postoperative clinical course varied only slightly between different animals. An original design of the cryoprobe used in the study played a primary role in the achieving of these results. The spinal cord lesion's detailed functional morphology is described at different time points (1-60 days) after the produced cryoinjury. Also, changes in the number of macrophages at distinct time points, neoangiogenesis and the formation of the glial scar's fibrous component, including morphodynamic characteristics of its evolution, are analyzed. The proposed method of cryoapplication for inducing reproducible glial scars could facilitate a better understanding of the self-recovery processes in the damaged spinal cord. It would be evidently helpful for finding innovative approaches to the SCI treatment.

Pediatric Cervical Spine Injuries and SCIWORA: WFNS Spine Committee Recommendations.

Cervical trauma in children have variations from the adults mainly due to anatomic differences. An optimal diagnostic and treatment strategy is critical, particularly when there is a lack of standardized protocols for the management of such cases. This review paper examines the diagnostic and treatment options of pediatric cervical trauma and Spinal Cord Injury Without Radiographic Abnormality (SCIWORA). A literature search for the last 10 years were conducted using key words. Case reports, experimental studies, papers other than English language were excluded. Up-to-date information on pediatric cervical trauma and SCIWORA were reviewed and statements were produced to reach a consensus in 2 separate consensus meeting of WFNS Spine Committee. The statements were voted and reached a consensus using Delphi method. This review reflects different aspects of contemporary pediatric cervical trauma decision-making and treatment, and SCIWORA. The mainstay of SCIWORA treatment is nonsurgical with immobilization, avoidance of risky activities. Prognosis generally depends on the initial neurological status and magnetic resonance imaging. Due to a significant discrepancy in the literature on diagnostic and management, future randomized controlled trials are needed to aid in generating standardized protocols.

Early Management of Cervical Spine Trauma: WFNS Spine Committee Recommendations.

Epidemiology, prevention, early management of cervical spine trauma and it's reduction are the objectives of this review paper. A PubMed and MEDLINE search between 2009 and 2019 were conducted using keywords. Case reports, experimental studies, papers other than English language and and unrelated studies were excluded. Up-to-date information on epidemiology of spine trauma, prevention, early emergency management, transportation, and closed reduction were reviewed and statements were produced to reach a consensus in 2 separate consensus meeting of World Federation of Neurosurgical Societies (WFNS) Spine Committee. The statements were voted and reached a positive or negative consensus using Delphi method. Global incidence of traumatic spinal injury is higher in low- and middle-income countries. The most frequent reasons are road traffic accidents and falls. The incidence from low falls in the elderly are increasing in high-income countries due to ageing populations. Prevention needs legislative, engineering, educational, and social efforts that need common efforts of all society. Emergency care of the trauma patient, transportation, and in-hospital acute management should be planned by implementing detailed protocols to prevent further damage to the spinal cord. This review summarizes the WFNS Spine Committee recommendations on epidemiology, prevention, and early management of cervical spine injuries.

Upper Cervical Spine Trauma: WFNS Spine Committee Recommendations.

Craniovertebral junction (CVJ) trauma is a challenging clinical condition. Being a highly mobile functional unit at the junction of the skull and the vertebral column, traumatic events in this area may produce devastating neurological complications and death. Additionally, many of the CVJ traumatic injuries can be left undiagnosed or even raise difficult treatment dilemmas. We present a literature review in the format of recommendations on the diagnosis and management of different scenarios for upper cervical trauma and produce recommendations, which can be applicable to various areas of the globe.

Spinal cord stimulation in chronic pain: technical advances.

Chronic severe pain results in a detrimental effect on the patient's quality of life. Such patients have to take a large number of medications, including opioids, often without satisfactory effect, sometimes leading to medication abuse and the pain worsening. Spinal cord stimulation (SCS) is one of the most effective technologies that, unlike other interventional pain treatment methods, achieves long-term results in patients suffering from chronic neuropathic pain. The first described mode of SCS was a conventional tonic stimulation, but now the novel modalities (high-frequency and burst), techniques (dorsal root ganglia stimulations), and technical development (wireless and implantable pulse generator-free systems) of SCS are becoming more popular. The improvement of SCS systems, their miniaturization, and the appearance of new mechanisms for anchoring electrodes results in a significant reduction in the rate of complications and revision surgeries, and the appearance of new waves of stimulation allows not only to avoid the phenomenon of addiction, but also to improve the long-term results of chronic SCS. The purpose of this review is to describe the current condition of SCS and up-to-date technical advances.

Learning Curve and Early Results of Interlaminar and Transforaminal Full-Endoscopic Resection of Lumbar Disc Herniations.

Background Full-endoscopic spinal surgery is an evolving technique. A laborious learning phase is inevitable due to the complexity of the orientation and instrumentation. The goal of the present study is to evaluate a single surgeon's learning curve and early outcomes in full-endoscopic resection of lumbar disc herniations. Methods This was a prospective non-controlled single-surgeon cohort study. In 54 patients with 57 herniations, 41 interlaminar and 16 transforaminal resections were performed. Surgery time, severity of adhesive process in the spinal canal, complication rates and clinical outcomes (VAS, ODI, custom questionnaire, recurrence and re-operation rate) were assessed. Results In the interlaminar group, operative time has decreased from 60 ± 20 min in the first 20 operations to 45 ± 14 min in the following 17 (p=0.023). In the transforaminal group, operative time has decreased from 60 ± 16 min in the first 7 operations to 41 ± 12 min in following 9 (p=0.023). Severe adhesive process in spinal canal was associated with duration of symptoms greater than 2 years, longer surgery and higher risk of surgical complications. Four recurrent disc herniations were re-operated using full-endoscopic technique. VAS, ODI and pain medications significantly decreased in both groups and in re-operated patients. Conclusion The plateau of the learning curve and good short-term clinical results of full-endoscopic interlaminar and transforaminal surgery may be achieved after twenty operations, given extensive previous experience in microsurgery. Risk of complications at the learning phase may be decreased by excluding the patients with symptoms lasting over two years.

Clipping versus coiling in posterior circulation intracranial aneurysms: a meta-analysis.

BACKGROUND: Posterior circulation intracranial aneurysm (IA) treatment remains challenging, due to the anatomy of the area and the high rupture possibility. Endovascular treatment seems to be more suitable for these aneurysms, but studies focused on endovascular treatment demonstrate a high rate of re-intervention needing. A meta-analysis might offer a clearer view, being useful in a more effective treatment planning. METHODS: A systematic search was performed, using the PubMed database platform. The final article pool contained 20 articles. Studied parameters were operative mortality, late mortality, permanent neurologic deficit (PND), and the need for re-intervention (Re-int). We divided patients into two subgroups, those with ruptured and those with unruptured aneurysm. Statistical analysis was performed using appropriate software. RESULTS: In the total population (645 patients), there was a superiority of coiling over clipping in terms of PND and of coiling in terms of Re-int. As regards mortality, there was no clear superiority of one method over the other. CONCLUSIONS: The current study came to the conclusion that there is a superiority of coiling over clipping in terms of PND. On the other hand, clipping seems to be superior to coiling in terms of the need for re-intervention. As regards mortality (both operative and late), there is no clear superiority of one method over the other. Studying subgroups of patients (ruptured and unruptured posterior circulation IAs), in terms of PND, there is no superiority of one method over the other. The same goes for Op-Mo on ruptured aneurysms.