Challenging assumptions: "unveiling meritocracy's reality in neurosurgery".

Introduction: Meritocracy, a concept revered as the cornerstone of fairness and equal opportunity, is critically examined in the context of neurosurgery. This article challenges the notion that success in this demanding field is solely determined by individual abilities and effort. It reveals that factors such as background, gender, and socioeconomic status significantly influence one's career trajectory. By investigating how these systemic barriers impact admissions to neurosurgical training programs and professional advancement, the paper underscores the complexity of meritocracy in neurosurgery, suggesting that the meritocratic ideal is more nuanced and influenced by external variables than commonly believed. Results: Certain universities deemed elite offer a curriculum divergent from that of their counterparts in low and middle-income countries. Students at these "elite" institutions gain exposure to new technologies and research incentives, which brings us to the realm of research. Remarkably, 75% of articles originating from developed nations account for just 25% of traumatic brain injury cases. This disparity highlights a significant research imbalance, and the common refrain underscores the need to bolster research capabilities in low-income countries. For neurosurgeons in the developing world, engaging in research often becomes a luxury due to multifaceted challenges. Financial barriers, including publication costs and paywalls for accessing articles, pose significant hurdles. Comparing salaries between countries underscores the glaring divide according to "Neurosurgeon Salary" in 2024. Neurosurgeons in the United States receive a median salary of $412,000 dollars per year, compared to $13,200 dollars in Latin America, as of June 2023. Given such incongruities, the prospect of even attending conferences or workshops abroad remains difficult for neurosurgeons from developing nations. Research isn't cast aside due to a lack of interest but due to resource limitations. The present landscape demands reconsideration. Conclusion: We underscore the journey towards a more inclusive and equitable future in neurosurgery as not just a goal, but a dynamic process fuelled by resilience, collaboration, and a commitment to diversity. The narrative promotes a collective endeavour to dismantle barriers and embrace innovation, emphasizing the importance of mentorship, cross-institutional collaboration, and the amplification of underrepresented voices.

A Differential Clinical Benefit Examination of Full Lumbar Endoscopy vs Interspinous Process Spacers in the Treatment of Spinal Stenosis: An Effect Size Meta-Analysis of Clinical Outcomes.

STUDY DESIGN: A design-agnostic standardized effect meta-analysis of 48 randomized, prospective, and retrospective studies on clinical outcomes with spinal endoscopic and interspinous process spacer (IPS) surgery. OBJECTIVE: The study aimed to provide reference set of Oswestry Disability Index (ODI) and visual analog scale (VAS) effect size data for back and leg pain following endoscopic and IPS decompression for lumbar herniated disc, foraminal, or lateral recess spinal stenosis. BACKGROUND: Mechanical low back pain following endoscopic transforaminal decompression may be more reliably reduced by simultaneous posterior column stabilization with IPS. METHODS: A systematic search of the PubMed, EMBASE, Web of Science, and the Cochrane Central Register of Controlled Trials from 1 January 2000 to 2 April 2020, identified 880 eligible endoscopy and 362 IPS studies varying in design and metrics. The authors compared calculated standardized effect sizes (Cohen's d) for extracted ODI, VAS-back, and VAS-leg data. RESULTS: The pooled standardized effect size combining the ODI, VAS-back, and VAS-leg data for the total sample of 19862 data sets from the 30 endoscopy and 18 IPS was 0.877 (95% CI = 0.857-0.898). When stratified by surgery, the combined effect sizes were 0.877 (95% CI = 0.849-0.905) for endoscopic decompression and 0.863 (95% CI = 0.796-0.930; P = 0.056) for IPS implantation. The ODI effect sizes calculated on 6462 samples with directly visualized endoscopic decompression were 0.917 (95% CI = 0.891-0.943) versus 0.798 (95% CI = 0.713-0.883; P < 0.001) with indirect IPS decompression (P < 0.001). The VAS-back effect sizes calculated on 3672 samples were 0.661 (95% CI = 0.585-0.738) for endoscopy and 0.784 (95% CI: 0.644-0.923; P = 0.187) for IPS. The VAS-leg effect sizes calculated on 7890 samples were 0.885 (95% CI = 0.852-0.917) for endoscopic decompression and 0.851 (95% CI = 0.767-0.935; P = 0.427). CONCLUSION: Lumbar IPS implantation produces larger reduction in low back pain than spinal endoscopy. On the basis of this meta-analysis, the combination of lumbar transforaminal endoscopy with simultaneous IPS has merits and should be formally investigated in higher grade clinical studies. CLINICAL RELEVANCE: Meta-analysis on the added clinical benefit of combining lumbar endoscopic decompression with an interspinous process spacer.

Differential Agnostic Effect Size Analysis of Lumbar Stenosis Surgeries.

STUDY DESIGN: A meta-analysis of 89 randomized prospective, prospective, and retrospective studies on spinal endoscopic surgery outcomes. OBJECTIVE: The study aimed to provide familiar Oswestry Disability Index (ODI), visual analog scale (VAS) back, and VAS leg effect size (ES) data following endoscopic decompression for sciatica-type back and leg pain due to lumbar herniated disc, foraminal, or lateral recess spinal stenosis. BACKGROUND: Higher-grade objective clinical outcome ES data are more suitable than lower-grade clinical evidence, including cross-sectional retrospective study outcomes or expert opinion to underpin the ongoing debate on whether or not to replace some of the traditional open and with other forms of minimally invasive spinal decompression surgeries such as the endoscopic technique. METHODS: A systematic search of PubMed, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials from 1 January 2000 to 31 December 2019 identified 89 eligible studies on lumbar endoscopic decompression surgery enrolling 23,290 patient samples using the ODI and VAS for back and leg pain used for the ES calculation. RESULTS: There was an overall mean overall reduction of ODI of 46.25 (SD 6.10), VAS back decrease of 3.29 (SD 0.65), and VAS leg reduction of 5.77 (SD 0.66), respectively. Reference tables of familiar ODI, VAS back, and VAS leg show no significant impact of study design, follow-up, or patients' age on ES observed with these outcome instruments. There was no correlation of ES with long-term follow-up (P = 0.091). Spinal endoscopy produced an overall ODI ES of 0.92 extrapolated from 81 studies totaling 12,710 patient samples. Provided study comparisons to tubular retractor microdiscectomy and open laminectomy showed an ODI ES of 0.9 (2895 patients pooled from 16 studies) and 0.93 (1188 patients pooled from 5 studies). The corresponding VAS leg ES were 0.92 (12,631 endoscopy patients pooled from 81 studies), 0.92 (2348 microdiscectomy patients pooled from 15 studies), and 0.89 (1188 open laminectomy patients pooled from 5 studies). CONCLUSION: Successful clinical outcomes can be achieved with various lumbar surgeries. ESs with endoscopic spinal surgery are on par with those found with open laminectomy and microsurgical decompression. CLINICAL RELEVANCE: This article is a meta-analysis on the benefit overlap between lumbar endoscopy, microsurgical decompression, laminectomy, and lumbar decompression fusion.

Three-Dimensional Plastic Modeling on Bone Frames for Cost-Effective Neuroanatomy Teaching.

Cadaveric models remain an essential part of medical training across all specialties. Due to their scarcity, high costs, and possible health hazards, there is a need for more accessible and affordable alternatives, especially in low-resource settings. We introduce cost-effective and easily replicable three-dimensional (3D) printed models to help democratize access to hands-on neuroanatomy education. Silicone-based glue is applied on the surface of a 3D-printed or cadaveric bone frame. Using plastiline on a 3 mm 3D acrylonitrile butadiene styrene pen, the desired anatomical structure is printed on the bone frame. A heat gun is used to smoothen the plastic edges. The structure can then be painted according to its appearance in the real anatomy. Using this technique, we successfully generated a variety of anatomical models to study the cerebrovascular anatomy, the course of the cranial nerves in relation to the skull base, and extracranial structures including the spine. Procurement and conservation of cadaveric specimens can be cumbersome. Our model may be an affordable and easily replicable approach to bridging the gap in anatomy education between low- and high-resource facilities.

Minimally Invasive Posterior Tubular Microsurgical Approach for the Management of Symptomatic Synovial Cysts of the Lumbar and Cervical Spine.

BACKGROUND: Synovial cysts are commonly associated with instability. Whether to fuse patients is a matter of controversy. Simple resection may offer favorable clinical outcomes but may come at the expense of recurrence rate. We describe our experience with the minimally invasive management of these lesions using microsurgical dissection through a tubular retractor system. MATERIALS: A retrospective cohort study of symptomatic patients with synovial cysts treated by a minimally invasive tubular approach from 2001 to 2018 was performed. We evaluated variables such as preexisting spinal pathology, previous surgery, radiological findings, comorbidities, and secondary surgery requiring fusion. We used the visual analog scale (VAS), the Oswestry disability index (ODI), and the Macnab scale for clinical evaluation. RESULTS: There were 35 patients with a mean age of 63 years. The mean duration of symptoms before surgery was 195 weeks. Axial pain was present in 77.1% of cases; radiculopathy was the main symptom in 94.3% of cases. The most frequent site was L4-L5 (62.8%). Presenting comorbidities were lumbar stenosis (28.6% of patients), spondylolisthesis (8.6%), and facet hypertrophy (31.4%). Mean surgical time was 143 minutes (range, 55-360 minutes). The mean hospital stay was 2 days, ranging from 1 to 5 days. No complications were encountered as a consequence of the surgical procedure. All patients showed neurophysiological improvement after surgical intervention. A total of 34 patients (97.14%) showed clinical improvement at the end of follow-up, averaging 17 months and ranging from 1 to 60 months, 28 patients (80%) had good to excellent Macnab outcomes, 6 patients (17.14%) were rated as fair, and 1 (2.86%) patient had a poor Macnab outcome. Radicular VAS significantly changed (P < .05) from a preoperative mean of 8.23 ± 1.24 to a postoperative mean of 2.23 ± 1.94. ODI significantly decreased (P < .05) from a preoperative of mean of 41.02 ± 12.56 to a postoperative of mean of 11.82 ± 10.56. We performed fusion at initial surgery in 37.1% of cases; however, 3 more patients required secondary fusion at follow-up. CONCLUSION: Our series corroborates the prior literature with a low incidence of synovial cysts in the cervical spine and none in the thoracic spine. The present work shows the efficacy of minimally invasive surgery in the treatment of these lesions. Synovial cysts were associated with instability, ultimately requiring fusion in the majority of patients. The authors' study includes a large patient series with minimally invasive microsurgical decompression performed through a tubular retractor to date. LEVEL OF EVIDENCE: 3.

Dural Tears During Lumbar Spinal Endoscopy: Surgeon Skill, Training, Incidence, Risk Factors, and Management.

BACKGROUND: Incidental dural tears during lumbar endoscopy can be challenging to manage. There is limited literature on their appropriate management, risk factors, and the clinical consequences of this typically uncommon complication. MATERIALS AND METHODS: To improve the statistical power of studying durotomy with lumbar endoscopy, we performed a retrospective survey study among endoscopic spine surgeons by email and chat groups on social media networks, including WhatsApp and WeChat. Descriptive and correlative statistics were done on the surgeons' recorded responses to multiple-choice questions. Surgeons were asked about their clinical experience with spinal endoscopy, training background, the types of lumbar endoscopic decompression they perform by approach, the decompression instruments they use, and incidental durotomy incidence with routine lumbar endoscopy. RESULTS: There were 689 dural tears in 64 470 lumbar endoscopies, resulting in an incidental durotomy incidence of 1.07%. Seventy percent of the durotomies were reported by 20.4% of the surgeons. Eliminating these 19 outlier surgeons yielded an adjusted durotomy rate of 0.32. Endoscopic stenosis decompression (54.8%; P < .0001), rather than endoscopic discectomy (44.1%; 41/93), was significantly more associated with durotomy. Medium-sized dural tears (1-10 mm) were the most common (52.2%; 48/93). Small pinhole durotomies (less than 1 mm) were the second most common type (46.7%; 43/93). Rootlet herniations were seen by 46.2% (43/93) of responding surgeons. The posterior dural sac injury during the interlaminar approach (57%; 53/93) occurred more frequently than traversing nerve-root injuries (31.2%) or anterior dural sac (23.7%; 22/93). Exiting nerve-root injuries (10.8%;10/93) were less common. Over half of surgeons did not attempt any repair or closure (52.2%; 47/90). Forty percent (36/90) used sealants. Only 7.8% (7/90) of surgeons attempted an endoscopic repair or sutures (11.1%; 10/90). DuralSeal was the most commonly used brand of commercially available sealant used (42.7%; 35/82). However, other sealants such as Tisseal (15.9%; 13/82), Evicel (2.4%2/82), and additional no-brand sealants (38; 32/82) were also used. Nearly half of the patients (48.3%; 43/89) were treated with 24-48 hours of bed rest. The majority of participating surgeons (64%; 57/89) reported that the long-term outcome was unaffected. Only 18% of surgeons reported having seen the development of a postoperative cerebrospinal fluid (CSF)-fistula (18%;16/89). However, the absolute incidence of CSF fistula was only 0.025% (16/64 470). Severe radiculopathy with dysesthesia; sensory loss; and motor weakness in association with an incidental durotomy were reported by 12.4% (11/89), 3.4% (3/89), and 2.2% (2/89) of surgeons, respectively. CONCLUSIONS: The incidence of dural tears with lumbar endoscopy is about 1%. The incidence of durotomy is higher with the use of power drills and the interlaminar approach. Stenosis decompression that typically requires the more aggressive use of these power instruments has a slightly higher incidence of dural tears than does endoscopic decompression for a herniated disc. Most dural tears are small and can be successfully managed with mechanical compression with Gelfoam and sealants. Two-thirds of patients with incidental dural tears had an entirely uneventful postoperative course. The remaining one-third of patients may develop a persistent CSF leak, radiculopathy with dysesthesia, sensory loss, or motor function loss. Patients should be educated preoperatively and reassured. LEVEL OF EVIDENCE: 3.

Current Workforce Status of the Neurosurgery Societies Belonging to the Latin American Federation of Neurosurgical Societies: A Survey of the Presidents of These Neurosurgery Societies.

BACKGROUND: The Latin American Federation of Neurosurgical Societies (FLANC) is a nongovernmental, nonprofit civil association, founded to promote neurosurgery in the Latin American countries. The American College of Surgeons and American Association of Neurological Surgeons has recommended a ratio of 1 neurosurgeon/100,000 inhabitants. We aimed to estimate the neurosurgical workforce of the FLANC in 2020. METHODS: We performed an internet-based survey of the presidents of the societies of the FLANC to obtain the neurosurgical workforce characteristics and demographics in their countries. We coded and blindly analyzed the information for dispersion measures and graphics using SPSS, version 25, and Microsoft Excel for map density building. We obtained ratios for the number of neurosurgeons/100,000 inhabitants and the inverse ratio (the number of inhabitants/1 neurosurgeon). RESULTS: We obtained information from 19 countries. The population totaled 650,008,765 inhabitants. The workforce included 9100 neurosurgeons for a composite within the FLANC of 1.4 neurosurgeons/100,000 inhabitants. The mean ratio among individual countries was 1.17, with as many as 9 countries having a ratio of <1 neurosurgeon/100,000 inhabitants. The proportion of female neurosurgeons in the FLANC was 9.54%. Seven countries had no neurosurgeons in a range of subspecialty fields. CONCLUSIONS: The FLANC has significant disparities in neurosurgical workforce ratios among the member countries. Central American countries probably have the greatest needs. Gender equity should also be improved among the training institutions. We encourage readers to develop future research into the local geographical distribution of neurosurgeons among the countries to better understand their needs and barriers to providing high-quality standards of care.

Scientific Contributions of the Mexican Association of Spine Surgeons (Asociación Mexicana de Cirujanos de Columna-AMCICO) to the Global Medical Literature: A 21-Year Systematic Review.

BACKGROUND: Contributions from Latin America to the global literature are scarce; until 2011, spine surgeons had published 320 articles in indexed journals. METHODS: This systematic review evaluates the scientific production of the Mexican Association of Spine Surgeons (Asociación Mexicana de Cirujanos de Columna-AMCICO) from its inception in 1998 to 2018 with the PRISMA statement using PubMed and Google Scholar search engines. The inclusion criteria were spine-related articles in indexed journals providing any (or no) level of evidence with ≥1 AMCICO member as an author. Journal metrics, article metrics, and author variables were analyzed using SPSS version 25. RESULTS: Of the 444 surgeons historically belonging to AMCICO, only 126 members contributed a total of 441 articles between 1998 and 2018. An average of 21.00 annual publications with an annual scientific output per capita of 0.05 was found. The most frequent evidence level was III (211 articles, 48%), the highest level was I (12 articles, 3%). The main study objective was clinical research, with 308 articles (70%), and the main study foci was trauma, with 103 articles (23%). An average impact factor of 0.16 and 0.92 was obtained for publications in Spanish and English, respectively. CONCLUSIONS: Scientific publications by AMCICO members are scarce, with a per capita annual index of 0.05 from a total of 441 articles in indexed journals. Second, the impact factor of these journals is low, with a mean value of 0.53. Further strategies should be implemented to increase the number and track the record of Mexican contributions to the scientific literature.

Microsurgical Resection of Intraspinal Benign Tumors Using Non-Expansile Tubular Access.

BACKGROUND: Intraspinal tumors are 10 to 15 times less common than brain tumors. The midline approach with extensive laminectomies represents the current gold-standard for resection, causing instability, muscle damage, and kyphosis among other well-known complications. Minimally invasive series reported their results using retractor-based systems. We analyzed a patient series treated with a non-expansile tubular approach, describing the technique, grade of resection, and clinical outcomes. METHODS: A series of consecutive cases operated between 2016 and October 2018 were analyzed retrospectively. The database included age, sex, clinical presentation, intraspinal location (intra/extradural), number of laminotomies, grade of resection, surgical time, bleeding, and follow-up. The initial and follow-up clinical condition was analyzed using the Frankel scale. RESULTS: A total of 13 patients underwent surgery: 3 intraspinal/extradural (23%), 8 intradural/extramedullary (61.5%), and 2 intramedullary tumors (15.3%); these were classified as 5 meningiomas (38.4%), 4 neurofibromas (30.7%), 2 schwannomas (15.3%), 1 hemangioblastoma (7.6%), and 1 astrocytoma (7.6%). Eleven (84.61%) patients had complete motor improvement, 1 patient had partial improvement, and 1 patient had no improvement (7.6% each). An 18-mm working channel tube was used for extramedullary lesions and 20-mm tubes for intramedullary injuries. Total tumor resection was achieved in 11 patients (84.6%) and subtotal in 2 patients (15.38%) corresponding to intramedullary tumors. CONCLUSIONS: Although this study consisted of a small series, we have shown the possibility of resecting intraspinal tumors (some intradural-intramedullary) with non-expansile tubes in a safe and effective way with no complications. Most of the patients had complete neurological improvement at the end of follow-up.

Ten-Step Minimally Invasive Cervical Decompression via Unilateral Tubular Laminotomy: Technical Note and Early Clinical Experience.

BACKGROUND: Minimally invasive techniques utilizing tubular retractors have become an increasingly popular approach to the spinal column. The concept of a unilateral laminotomy for bilateral decompression (ULBD), first applied in the lumbar spine, has recently been applied to the cervical spine for the treatment of cervical spondylotic myelopathy (CSM). A better understanding of the indications and surgical techniques is required to effectively educate surgeons on how to appropriately and safely perform tubular cervical laminotomy via ULBD. OBJECTIVE: To describe a 10-step technique for minimally invasive cervical laminotomy and report our early clinical experience. METHODS: A retrospective review identified 15 patients with CSM who were treated with this procedure. Visual analogue scale (VAS), neck disability index (NDI), and modified Japanese Orthopaedic Association (mJOA) scores were obtained pre- and postoperatively. RESULTS: The mean age of the 15 patients was 73.1 ± 6.8 yr. The median number of levels treated was 1 (range 1-3). Mean operative time was 125.3 ± 30.8 or 81.7 ± 19.2 min per level. Mean estimated blood loss was 57.3 ± 24.6 cc. Median postoperative hospital length of stay was 36 h. No complications were encountered. Median follow-up was 18 mo. Mean pre- and postoperative VAS were 6.4 ± 2.4 and 1.0 ± 0.8, respectively (P < .001). Mean pre- and postoperative NDI were 46.4 ± 19.2 and 7.0 ± 6.9, respectively (P < .001). Mean pre- and postoperative Mjoa were 11.3 ± 2.5 and 14.5 ± 0.5, respectively (P < .001). CONCLUSION: In our early clinical experience, minimally invasive cervical ULBD is safe and effective. Adherence to the presented 10-step technique will allow surgeons to safely address bilateral cervical pathology while avoiding complications.

Early Report on the Impact of COVID-19 Outbreak in Neurosurgical Practice Among Members of the Latin American Federation of Neurosurgical Societies.

BACKGROUND: The COVID-19 pandemic has caused severe economic consequences by local governmental measures to contain the outbreak. We provide insight on the impact that health care restriction has made on neurosurgical activity in Latin Iberoamerica. METHODS: We performed an internet-based survey among presidents and members of the societies of the Latin American Federation of Neurosurgical Societies (FLANC). We blindly analyzed information regarding local conditions and their impact on neurosurgical praxis using SPSS software. RESULTS: Information came from 21 countries. Sixteen society presidents reported having suspended regular activities and deferring local scheduled congresses, 14 reported mandatory isolation by government, and 4 instituted a telemedicine project. Four-hundred eighty-six colleagues, mean age 49 years, reported a mean 79% reduction in their neurosurgical praxis. Seventy-six percent of neurosurgeons have savings to self-support for 3-6 months if restrictions are long lasting. CONCLUSIONS: Stopping activities among societies of the FLANC, together with a drop of 79% of neurosurgical praxis, adds to deficits in provider's protection equipment and increasing demand for attention in the health care systems, representing a huge financial risk to their sustainability. Neurosurgeons should be involved in local policies to protect health and economy. Telemedicine represents an excellent solution, avoiding another pandemic of severe diseases across all-specialties as nonessential care can turn essential if left untreated. Financial support and ethics code review is needed to battle this new disease, designated the occupational disease of the decade, that continues to scrag the health care system. Times of crisis are times of great opportunities for humanity to evolve.

Segmental T12 Vertebral Artery Injury Treated by Endovascular Coil Placement after Kyphoplasty for Symptomatic Spinal Angioma. Case Report of a Minimal Invasive Solution for a Complication of a Minimally Invasive Spine Procedure.

BACKGROUND: Vertebral angioma is a tumor defined as an abnormality of vascular tissue development. It usually has an asymptomatic behavior, being present in 10%-12% of autopsies and imaging studies. CASE DESCRIPTION: A 70-year-old man consulted because of a long history of low back pain. Imaging studies were compatible with vertebral angioma at T12; we decided to perform a minimally invasive surgical procedure, such as kyphoplasty. During surgery, there was a sharp decrease in pulmonary saturation, and the patient underwent a computed tomography scan evaluation confirming a left hemothorax due to segmental branch vascular injury at T12. Given the patient's poor medical condition and the complexity of an emergent open procedure in the thoracic spine, we decided to undertake a minimally invasive endovascular coil placement to repair the vascular injury. Due to a favorable outcome, we discharged the patient after 72 hours of surveillance. CONCLUSIONS: Even in the case of a complication to occur, we should always consider a minimally invasive solution to solve the problem because patients undergoing these procedures correspond to elderly patients with poor medical conditions or comorbidities.

Radiological diagnostic accuracy study comparing Lenke, Bridwell, BSF, and CT-HU fusion grading scales for minimally invasive lumbar interbody fusion spine surgery and its correlation to clinical outcome.

Prospective randomized double-blinded diagnostic accuracy study about radiological grading of fusion after minimally invasive lumbar interbody fusion procedures (MI-LIFP).To determinate the intra and the inter-observer correlation between different radiological lumbar interbody fusion grading scales (RLIFGS) in patients undergoing MI-LIFP and their correlation to clinical outcome.Besides technological improvements in medical diagnosis and the many existing RLIFGS, surgical exploration continues to be the gold-standard to assess fusion in patients with radiological pseudarthrosis, with little if any research on the relationship between RLIFGS and clinical outcome.We collected data from patients undergoing MI-LIFP procedures operated by a single surgeon from 2009 to 2017, which had follow-up and CT-scan control greater than 12 months, whose clinical registers specified lumbar and radicular visual analogue scale (L and R-VAS) and Oswestry Disability Index (ODI) score preoperatively and at the end of follow-up. Interbody fusion levels were coded for blinded evaluation by three different minimally invasive spine (MIS) surgeons, using Lenke, Bridwell, BSF (Brantigan, Steffe, Fraser), and CT-HU RLIFGS. We established fusion criteria, as described in their original papers. Another independent spine surgeon blindly evaluated successful clinical outcome (SCO), defined as a significant improvement in 2 of 3 of the following issues: L-VAS, R-VAS, or ODI score at follow-up; otherwise, rated as clinical pseudarthrosis. Radiological and clinical data was coded and statistically analyzed using Student T-Test, Pearson P-Test, and ANOVA with statistical package for the social sciences 21 by another blinded researcher, positive and negative predictive values were also calculated for each RLFGS.We found a significant clinical improvement with a moderate intra-observer correlation between scales and no inter-observer or clinical correlation, with no sub-group statistically significant differences.This paper represents the first study about the diagnostic accuracy of RLFGS, we concluded that their diagnostic accuracy is pretty low to determine fusion or pseudoarthrosis based on its low correlation to clinical outcome, we recommend surgeons rely on clinical findings to decide whether a patient has clinical fusion or pseudoarthrosis based on successful clinical outcome.

Surgeon training and clinical implementation of spinal endoscopy in routine practice: results of a global survey.

BACKGROUND: Training of spine surgeons may impact the availability of contemporary minimally invasive spinal surgery (MIS) to patients and drive spine surgeons' clinical decision-making when applying minimally invasive spinal surgery techniques (MISST) to the treatment of common degenerative conditions of the lumbar spine. Training requirements and implementation of privileges vary in different parts of the world. The purpose of this study was to analyze the training in relation to practice patterns of surgeons who perform lumbar endoscopic spinal surgery the world over. METHODS: The authors solicited responses to an online survey sent to spine surgeons by email, and chat groups in social media networks including Facebook, WeChat, WhatsApp, and Linkedin. Surgeons were asked the following questions: (I) please indicate your training? (II) What type of MISST spinal surgery do you perform? (III) How would you rate your experience in MIS lumbar spinal surgery and what percentage of your practice is MISST? And (IV) which avenue did you use to train for the MISST you currently employ in your clinical practice today? Descriptive statistics were applied to count responses and cross-tabulated them to the surgeon's training. Pearson Chi-square measures, kappa statistics, and linear regression analysis of agreement or disagreement were performed by analyzing the distribution of variances using statistical package SPSS version 25.0. RESULTS: A total of 430 surgeons accessed the survey. The completion rate was 67.4%. Analyzing the responses of 292 surveys submitted by 97 neurosurgeons (33.2%), 161 orthopaedic surgeons (55.1%), and 34 surgeons of other postgraduate training (11.6%) showed that only 14% (41/292) of surgeons had completed a fellowship. Surgeons rated their skill level 33.5% of the time as master and experienced surgeon, and 35.6% of the time as novice or surgeon with some experience. There were more master (64.6% versus 29.2%) and experienced (52% versus 40%) surgeons amongst orthopaedic surgeons than amongst neurosurgeons at a statistically significant level (P=0.11). There were near twice as many orthopaedic surgeons (54.3%) using endoscopic procedures in the lumbar spine as their favorite MISST than neurosurgeons (35.4%; P=0.096). Endoscopic spine surgeons' main sources of knowledge acquisition were (I) learning in small meetings (57.3%), (II) attending workshops (63.1%), and (III) national and international conferences (59.8%). CONCLUSIONS: The majority of spine surgeons reported more than half of their cases employing MISST at a high skill level. Very few MISST surgeons are fellowship trained but attend workshops and various meetings suggesting that many of them are self-thought. Orthopaedic surgeons were more likely to implement endoscopic spinal surgery into the routine clinical practice. As endoscopic spine surgery gains more traction and patient demand, minimal adequate training will be part of the ongoing debate.

Surgeon motivation, and obstacles to the implementation of minimally invasive spinal surgery techniques.

BACKGROUND: This study aimed to analyze the motivators and obstacles to the implementation of minimally invasive spinal surgery techniques (MISST) by spinal surgeons. Motivators and detractors may impact the availability of MISST to patients and drive spine surgeons' clinical decision-making in the treatment of common degenerative conditions of the lumbar spine. METHODS: The authors solicited responses to an online survey sent to spine surgeons by email, and chat groups in social media networks including Facebook, WeChat, WhatsApp, and Linkedin. Descriptive statistics were employed to count the responses and compared to the surgeon's training. Kappa statistics and linear regression analysis of agreement were performed. RESULTS: A total of 430 surgeons accessed the survey. The completion rate was 67.4%. A total of 292 surveys were submitted by 99 neurosurgeons (33.9%), 170 orthopaedic surgeons (58.2%), and 23 surgeons of other postgraduate training (7.9%). Personal interest (82.5%) and patient demand (48.6%) were the primary motivators for MISST implementation. High equipment (48.3%) and disposables (29.1%) cost were relevant obstacles to MISST implementation. Local workshops (47.6%) and meetings in small groups (31.8%) were listed as the primary knowledge sources. Only 12% of surgeons were fellowship trained, but 46.3% of surgeons employed MISST in over 25% of their cases. CONCLUSIONS: The rate of implementation of MISST reported by spine surgeons was found to be high but impeded by the high cost of equipment and disposables. The primary motivators for spine surgeons' desire to implement were personal interest and patient demand.

Regional variations in acceptance, and utilization of minimally invasive spinal surgery techniques among spine surgeons: results of a global survey.

BACKGROUND: Regional differences in acceptance and utilization of MISST by spine surgeons may have an impact on clinical decision-making and the surgical treatment of common degenerative conditions of the lumbar spine. The purpose of this study was to analyze the acceptance and utilization of various minimally invasive spinal surgery techniques (MISST) by spinal surgeons the world over. METHODS: The authors solicited responses to an online survey sent to spine surgeons by email, and chat groups in social media networks including Facebook, WeChat, WhatsApp, and Linkedin. Surgeons were asked the following questions: (I) Do you think minimally invasive spinal surgery is considered mainstream in your area and practice setting? (II) Do you perform minimally invasive spinal surgery? (III) What type of MIS spinal surgery do you perform? (IV) If you are performing endoscopic spinal decompression surgeries, which approach do you prefer? The responses were cross-tabulated by surgeons' demographic data, and their practice area using the following five global regions: Africa & Middle East, Asia, Europe, North America, and South America. Pearson Chi-Square measures, Kappa statistics, and linear regression analysis of agreement or disagreement were performed by analyzing the distribution of variances using statistical package SPSS Version 25.0. RESULTS: A total of 586 surgeons accessed the survey. Analyzing the responses of 292 submitted surveys regional differences in opinion amongst spine surgeons showed that the highest percentage of surgeons in Asia (72.8%) and South America (70.2%) thought that MISST was accepted into mainstream spinal surgery in their practice area (P=0.04) versus North America (62.8%), Europe (52.8%), and Africa & Middle East region (50%). The percentage of spine surgeons employing MISST was much higher per region than the rate of surgeons who thought it was mainstream: Asia (96.7%), Europe (88.9%), South America (88.9%), and Africa & Middle East (87.5%). Surgeons in North America reported the lowest rate of MISST implementation globally (P<0.000). Spinal endoscopy (59.9%) is currently the most commonly employed MISST globally followed by mini-open approaches (55.1%), and tubular retractor systems (41.8%). The most preferred endoscopic approach to the spine is the transforaminal technique (56.2%) followed by interlaminar (41.8%), full endoscopic (35.3%), and over the top MISST (13.7%). CONCLUSIONS: The rate of implementation of MISST into day-to-day clinical practice reported by spine surgeons was universally higher than the perceived acceptance rates of MISST into the mainstream by their peers in their practice area. The survey suggests that endoscopic spinal surgery is now the most commonly performed MISST.

Assessment of Paraspinal Muscle Atrophy Percentage after Minimally Invasive Transforaminal Lumbar Interbody Fusion and Unilateral Instrumentation Using a Novel Contralateral Intact Muscle-Controlled Model.

STUDY DESIGN: Retrospective comparative clinical study. PURPOSE: This study aimed to assess paraspinal muscle atrophy in patients who underwent minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) and unilateral pedicle screw fixation using a novel contralateral intact muscle-controlled model. OVERVIEW OF LITERATURE: The increased incidence of paravertebral lumbar muscle injuries after open techniques has raised the importance of implementing minimally invasive spine surgical techniques using tubular retractors and minimally invasive screw placement. The functional cross-sectional area (FCSA) represents the lean muscle mass; furthermore, FCSA is a useful marker of the contractile ability of a muscle following a spine surgery. However, the benefits of unilateral fixation and MI-TLIF on paraspinal muscles have not been defined. METHODS: We performed a retrospective imagenological review on eleven patients who underwent unilateral MI-TLIF and unilateral transpedicular screw lumbar placement. FCSAs of the multifidus and erector spinae were measured 1 year after surgery at adjacent levels and were compared to the contralateral intact muscles. Measurement differences between the surgical and nonsurgical sites were compared. The interobserver reliability was calculated using an intraclass correlation coefficient. RESULTS: The mean FCSA at the surgical site was 20.97±5.07 cm2 at the superior level and 8.89±2.87 cm2 at the inferior level. The mean FCSA at the contralateral nonsurgical site was 20.15±5.95 cm2 at the superior level and 9.20±2.66 cm2 at the inferior level was. The superior and inferior FCSA measurements showed no significant difference between the surgical and nonsurgical sites (p=0.5, p=0.922, respectively). CONCLUSIONS: Using a mini-open tubular approach through the sulcus between the longissimus and iliocostalis, MI-TLIF and unilateral pedicle screw instrumentation produced minimal paraspinal muscle damage at the superior and inferior adjacent levels.

A prospective clinical study comparing MI-TLIF with unilateral versus bilateral transpedicular fixation in low grade lumbar spondylolisthesis.

BACKGROUND: Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) has become one of the standard techniques for approaching ipsilateral decompression, anterior column fusion, and posterior stabilization. This procedure is usually accompanied by the placement of bilateral transpedicular screws in the corresponding segment. The purpose of this study was to evaluate the clinical efficacy of unilateral screw fixation compared with bilateral fixation in patients diagnosed with low-grade symptomatic lumbar spondylolisthesis who underwent an MI-TLIF technique. METHODS: A prospective and comparative study was performed in 67 patients with grade 1 symptomatic lumbar spondylolisthesis. The sample was allocated on both unilateral fixation group (n=33) and bilateral fixation group (n=34). Clinical outcomes were evaluated using Oswestry Disability Index (ODI), visual analogue scale (VAS) for leg and back pain, and Short Form 36 Health Survey (SF-36), preoperatively, and at 1, 3, 6, and 12 months postoperatively. Changes over time and differences between the groups were analyzed. Statistical analyses included: Friedman test, Student's t-test and Mann-Whitney's U. A two-tailed P value of <0.05 was considered significant. RESULTS: During 1-year of evaluation there were no significant clinical differences between both groups. CONCLUSIONS: Patients with grade 1 symptomatic lumbar spondylolisthesis treated with MI-TLIF with unilateral screw fixation had similar clinical results than those treated with bilateral fixation at 12 months postoperatively.

Microscopy-assisted interspinous tubular approach for lumbar spinal stenosis.

Various minimally invasive techniques have been reported as an alternative to conventional lumbar decompression. The major advantage of these minimally invasive procedures lies in their reduction of unnecessary exposure and tissue trauma. Our objective was to describe a minimally invasive procedure for lumbar spinal stenosis decompression by enlarging the lumbar interspinous space, approaching it with a tubular retractor, and assisting with microscopy. Thoracolumbar fascia and paravertebral muscles are preserved throughout the whole procedure. Iatrogenic instability of the spine can be avoided if during the procedure both joints are just undercut in order to decompress the subarticular space. The approach described in this manuscript could be used as an alternate minimally invasive surgical procedure for the treatment of central and lateral lumbar spinal stenosis.