Recent Trends in Neurosurgery Career Outcomes in Canada.

BACKGROUND: As with other specialties, Royal College of Physicians and Surgeons of Canada (RCPSC) trainees in Neurosurgery have anecdotally had challenges securing full-time employment. This study presents the employment status, research pursuits, and fellowship choices of neurosurgery trainees in Canadian programs. METHODS: RCPSC neurosurgery trainees (n = 143) who began their residency training between 1998 and 2008 were included in this study. Associations between year of residency completion, research pursuits, and fellowship choice with career outcomes were determined by Fisher's exact test (p < 0.05, statistical significance). RESULTS: In 2015, 60% and 26% of neurosurgery trainees had permanent positions in Canada and the USA, respectively. Underemployment, defined as locum and clinical associate positions, pursuit of multiple unrelated fellowships, unemployment, and career change to non-surgical career, was 12% in 2015. The proportion of neurosurgery trainees who had been underemployed at some point within 5 years since residency completion was 20%. Pursuit of in-folded research (MSc, PhD, or non-degree research greater than 1 year) was significantly associated with obtaining full employment (94% vs. 73%, p = 0.011). However, fellowship training was not significantly associated with obtaining full employment (78% vs. 75%, p = 1.000). CONCLUSIONS: Underemployment in neurosurgery has become a significant issue in Canada for various reasons. Pursuit of in-folded research, but not fellowship training, was associated with obtaining full employment.

Tendances récentes au Canada en ce qui regarde les possibilités d'emploi en neurochirurgie.Contexte: À l'instar d'autres stagiaires de la médecine spécialisée, des stagiaires en neurochirurgie membres du Collège royal des médecins et des chirurgiens du Canada (CRMCC) ont dit éprouver, selon des données empiriques, des difficultés à obtenir un emploi à plein temps. Cette étude entend présenter la situation professionnelle des stagiaires inscrits dans des programmes canadiens en neurochirurgie ainsi que leurs activités de recherche et leurs choix en matière de bourses de recherche postdoctorale. Méthodes : Des stagiaires membres du CRMCC ayant entrepris leur résidence entre 1998 et 2008 (n = 143) ont été inclus dans cette étude. Les liens pouvant exister entre l'année de résidence complétée, les activités de recherche, les choix en matière de bourses de recherche postdoctorale et les possibilités d'emploi ont été déterminés au moyen du test exact de Fisher (p < 0,05 ; signification statistique). Résultats : En 2015, 60 % des stagiaires en neurochirurgie du Canada disaient compter sur un poste permanent alors qu'ils étaient 26 % à affirmer la même chose aux États-Unis. Le sous-emploi, défini comme par des postes de suppléant (locum) et de clinicien adjoint, par l'obtention de plusieurs bourses de recherche postdoctorale sans liens apparents, par le chômage et par un changement d'orientation excluant la chirurgie, atteignait 12 % la même année. La proportion de stagiaires disant avoir été sous-employés à un moment ou un autre au cours des 5 années de leur résidence était par ailleurs de 20 %. Le fait de mener un projet de recherche dans le cadre de sa résidence (M.Sc., Ph.D. ou en dehors des cycles supérieurs pendant au moins 12 mois) était clairement associé à l'obtention d'un emploi à temps plein (94 % contre 73 % ; p = 0,011). Cela dit, une formation offerte à la suite de l'obtention d'une bourse de recherche postdoctorale n'a pas été associée de manière notable à l'obtention d'un emploi à temps plein (78 % contre 75 % ; p = 1,000). Conclusions : Le sous-emploi en neurochirurgie est désormais un enjeu important au Canada, et ce, pour toutes sortes de raisons. Contrairement aux formations liées à l'obtention d'une bourse de recherche postdoctorale, le fait de mener un projet de recherche régulier a été associé à l'obtention d'un emploi à temps plein.

Canadian neurosurgeons' views on medical assistance in dying (MAID): a cross-sectional survey of Canadian Neurosurgical Society (CNSS) members.

BACKGROUND: The Supreme Court of Canada removed the prohibition on physicians assisting in patients dying on 6 February 2015. Bill C-14, legalising medical assistance in dying (MAID) in Canada, was subsequently passed by the House of Commons and the Senate on 17 June 2016. As this remains a divisive issue for physicians, the Canadian Neurosurgical Society (CNSS) has recently published a position statement on MAID. METHODS: We conducted a cross-sectional survey to understand the views and perceptions among CNSS members regarding MAID to inform its position statement on the issue. Data was collected from May to June 2016. RESULTS: Of the 300 active membes of the CNSS who recevied the survey, 89 respondents completed the survey, 71% of whom were attending neurosurgeons and 29% were neurosurgery residents. Most respondents,74.2%, supported the right of physicians to participate in MAID with 7.8% opposing. 37% had current patients in their practice fitting the criteria for MAID. 23.6% had been asked by patients to assist with MAID, but only 11% would consider personally providing it. 84% of neurosurgeons surveyed supported the physicians' right to conscientious objection to MAID while 21% thought attending surgeons should be removed from the inquiry and decision-making process. 43.8% agreed that the requirment to refer a patient to a MAID service should be mandatory. Glioblastoma multiforme (65%), quadriplegia/quadriparesis secondary to spinal tumour/trauma (54%) and Parkinson's disease (24%) were the most common suggested potential indications for MAID among the neurosurgical population. CONCLUSIONS: Our results demonstrate that most neurosurgeons in Canada are generally supportive of MAID in select patients. However, they also strongly support the physicians' right to conscientious objection.

Peripheral dysgraphia: dissociations of lowercase from uppercase letters and of print from cursive writing.

Clinical analyses of patients with acquired dysgraphia provide unique opportunities to understand the cognitive and neural organization of written language production. We report J.B., a 50-year-old woman with peripheral dysgraphia who had prominent dissociations in her ability to write in lowercase versus uppercase and print versus cursive. We gave J.B. a series of tasks that evaluated her skills at writing uppercase and lowercase print and cursive, spelling aloud and in writing, writing numbers and symbols, and visual letter recognition and imagery. She was impaired in printing letters, with lowercase more affected than uppercase, but her cursive writing was relatively intact. This pattern was consistent across letter, word, and nonword writing tasks. She was unimpaired on tasks assessing her visual recognition and imagery of lowercase and uppercase letters. Her writing of numbers was preserved. J.B.'s handwriting disorder was accompanied by a central phonological dysgraphia. Our findings indicate functional independence of graphomotor programs for print and cursive letter styles and for letters and numbers. We discuss the relationship between peripheral and central writing disorders.

Outcome of stereotactic radiotherapy for patients with uncontrolled acromegaly.

OBJECTIVE: Linear accelerator based stereotactic radiation therapy (SRT) has been used for the treatment of pituitary tumours; however, little is known concerning the use of this modality for the treatment of patients with acromegaly. We have prospectively studied the short-term outcome of SRT in 12 acromegaly patients who failed to achieve biochemical remission despite surgery and/or pharmacologic therapy. METHODS: We identified all patients who had biochemically uncontrolled acromegaly and were treated with SRT between April 2003 and December 2006. All patients were followed prospectively based on a pre-defined protocol that included Goldman visual field examination, MRI of the sella, and pituitary hormone testing at 3, 6, 12 months, and then yearly. RESULTS: A total of 12 patients with acromegaly were treated with SRT. There were 9 females and the median age of the group was 50 years. The median follow-up was 28.5 months during which time the mean tumor volume decreased by 40%, the median GH fell from 4.1 microg/L to 1.3 microg/L (p = 0.003) and the median IGF-1 dropped more than half from 545.5 microg/L to 260.5 microg/L (p = 0.002). Four patients achieved normal, while an additional 2 achieved near-normal, IGF-1 levels. One patient was able to discontinue and two were able to reduce their acromegaly medications while maintaining a normal IGF-1. A new pituitary hormonal deficit was found at 24 months in one patient who developed hypoadrenalism requiring corticosteroid replacement. CONCLUSION: Based on our early experience, we believe that SRT should be considered in treating patients with uncontrolled acromegaly.

Anterograde ventricular irrigation during fourth ventricle region surgery.

OBJECTIVE: To reduce postoperative hydrocephalus following surgery in the region of the fourth ventricle. METHOD/TECHNIQUE: We describe the use of a conventionally placed lateral ventricular catheter to facilitate anterograde ventricular irrigation during surgery in the region of the fourth ventricle. This technique offers a safe alternative to more conventional approaches to fourth ventricular irrigation and obviates the need for placement of a third or fourth ventricular catheter and/or serial lumbar punctures by thoroughly flushing blood and tissue debris from the operative field at the time of surgery. RESULTS: Preliminary results spanning a five-year period show a lower incidence in the need for early ventriculo-peritoneal shunts (5%) and delayed ventriculo-peritoneal shunts (10%). CONCLUSION: This technique represents a safe method of reducing hydrocephalus following operative procedures in the region of the fourth ventricle.

Deep arteriovenous malformations of the basal ganglia and thalamus: natural history.

OBJECT: Patients with arteriovenous malformations (AVMs) in a deep location and with deep venous drainage are thought to be at higher risk for hemorrhage than those with AVMs in other locations. Despite this, the natural history of AVMs of the basal ganglia and thalamus has not been well studied. METHODS: The authors retrospectively evaluated a cohort of 96 patients with AVMs in the basal ganglia and thalamus with respect to the tendency of these lesions to hemorrhage between the time of detection and their eventual successful management. The 96 patients studied had a mean age of 22.7 years at diagnosis, and 51% were male. Intracranial hemorrhage (ICH) was the event leading to clinical detection in 69 patients (71.9%), and 85.5% of these patients were left with hemiparesis. After diagnosis, 25 patients bled a total of 49 times. The cumulative clinical follow up after detection but before surgical management was 500.2 patient-years. The risk of hemorrhage after detection of an AVM of the basal ganglia or thalamus was 9.8% per patient-year. CONCLUSIONS: The rate of ICH in patients with AVMs of the basal ganglia or thalamus (9.8%/year) is much higher than the rate in patients with AVMs in other locations (2-4%/year). The risk of incurring a neurological deficit with each hemorrhagic event is high. Treatment of these patients at specialized centers is recommended to prevent neurological injury from a spontaneous ICH.

Functional motor neurons differentiating from mouse multipotent spinal cord precursor cells in culture and after transplantation into transected sciatic nerve.

OBJECT: One of the current challenges in neurobiology is to ensure that neural precursor cells differentiate into specific neuron types, so that they can be used for transplantation purposes in patients with neuron loss. The goal of this study was to determine if spinal cord precursor cells could differentiate into motor neurons both in culture and following transplantation into a transected sciatic nerve. METHODS: In cultures with trophic factors, neurons differentiate from embryonic precursor cells and express motor neuronal markers such as choline acetyltransferase (ChAT), Islet-1, and REG2. Reverse transcription-polymerase chain reaction analysis has also demonstrated the expression of Islet-1 in differentiated cultures. A coculture preparation of neurospheres and skeletal myocytes was used to show the formation of neuromuscular connections between precursor cell-derived neurons and myocytes both immunohistochemically and electrophysiologically. Following various survival intervals, precursor cells transplanted distal to a transection of the sciatic nerve differentiated into neurons expressing the motor neuron markers ChAT and the alpha1 1.2 (class C, L-type) voltage-sensitive Ca++ channel subunit. These cells extended axons into the muscle, where they formed cholinergic terminals. CONCLUSIONS: These results demonstrate that motor neurons can differentiate from spinal cord neural precursor cells grown in culture as well as following transplantation into a transected peripheral nerve.

Safety and efficacy of NA-1 in patients with iatrogenic stroke after endovascular aneurysm repair (ENACT): a phase 2, randomised, double-blind, placebo-controlled trial.

BACKGROUND: Neuroprotection with NA-1 (Tat-NR2B9c), an inhibitor of postsynaptic density-95 protein, has been shown in a primate model of stroke. We assessed whether NA-1 could reduce ischaemic brain damage in human beings. METHODS: For this double-blind, randomised, controlled study, we enrolled patients aged 18 years or older who had a ruptured or unruptured intracranial aneurysm amenable to endovascular repair from 14 hospitals in Canada and the USA. We used a computer-generated randomisation sequence to allocate patients to receive an intravenous infusion of either NA-1 or saline control at the end of their endovascular procedure (1:1; stratified by site, age, and aneurysm status). Both patients and investigators were masked to treatment allocation. The primary outcome was safety and primary clinical outcomes were the number and volume of new ischaemic strokes defined by MRI at 12-95 h after infusion. We used a modified intention-to-treat (mITT) analysis. This trial is registered with ClinicalTrials.gov, number NCT00728182. FINDINGS: Between Sept 16, 2008, and March 30, 2011, we randomly allocated 197 patients to treatment-12 individuals did not receive treatment because they were found to be ineligible after randomisation, so the mITT population consisted of 185 individuals, 92 in the NA-1 group and 93 in the placebo group. Two minor adverse events were adjudged to be associated with NA-1; no serious adverse events were attributable to NA-1. We recorded no difference between groups in the volume of lesions by either diffusion-weighted MRI (adjusted p value=0·120) or fluid-attenuated inversion recovery MRI (adjusted p value=0·236). Patients in the NA-1 group sustained fewer ischaemic infarcts than did patients in the placebo group, as gauged by diffusion-weighted MRI (adjusted incidence rate ratio 0·53, 95% CI 0·38-0·74) and fluid-attenuated inversion recovery MRI (0·59, 0·42-0·83). INTERPRETATION: Our findings suggest that neuroprotection in human ischaemic stroke is possible and that it should be investigated in larger trials. FUNDING: NoNO Inc and Arbor Vita Corp.

Arteriovenous malformations.

Arteriovenous malformations of the brain are congenital vascular lesions that affect 0.01-0.50% of the population, and are generally present in patients aged 20-40 years. The usual clinical presentations are haemorrhage, seizures, progressive neurological deficit, or headache. Results of natural history studies have shown a yearly haemorrhage rate of 1-4%. Frequency of rebleeding has increased over the years, and several factors that increase risk of haemorrhage have been identified. Although substantial, the morbidity associated with haemorrhages could be less than previously thought. Over the past decade, great advances have been made in application of endovascular embolisation techniques, stereotactic radiosurgery, and microsurgery, allowing effective multidisciplinary treatment of arteriovenous malformations, including those previously deemed to be untreatable. Increasing attention has been paid to management of flow-related aneurysms associated with these malformations. Finally, many reports of recurrent arteriovenous malformations have coincided with new theories regarding the embryogenesis of these disorders and laboratory work suggesting their proliferative potential.