IL-12p40 promotes secondary damage and functional impairment after spinal cord contusional injury.

Secondary damage obstructs functional recovery for individuals who have sustained a spinal cord injury (SCI). Two processes significantly contributing to tissue damage after trauma are spinal cord hemorrhage and inflammation: more specifically, the recruitment and activation of immune cells, frequently driven by pro-inflammatory factors. Cytokines are inflammatory mediators capable of modulating the immune response. While cytokines are necessary to elicit inflammation for proper healing, excessive inflammation can result in destructive processes. The pro-inflammatory cytokines IL-12 and IL-23 are pathogenic in multiple autoimmune diseases. The cytokine subunit IL-12p40 is necessary to form bioactive IL-12 and IL-23. In this study, we examined the relationship between spinal cord hemorrhage and IL-12-related factors, as well as the impact of IL-12p40 (IL-12/IL-23) on secondary damage and functional recovery after SCI. Using in vivo magnetic resonance imaging and protein tissue analyses, we demonstrated a positive correlation between IL-12 and tissue hemorrhage. Receptor and ligand subunits of IL-12 were significantly upregulated after injury and colocalized with astrocytes, demonstrating a myriad of opportunities for IL-12 to induce an inflammatory response. IL-12p40-/- mice demonstrated significantly improved functional recovery and reduced lesion sizes compared to wild-type mice. Targeted gene array analysis in wild-type and IL-12p40-/- female mice after SCI revealed an upregulation of genes associated with worsened recovery after SCI. Taken together, our data reveal a pathogenic role of IL-12p40 in the secondary damage after SCI, hindering functional recovery. IL-12p40 (IL-12/IL-23) is thus an enticing neuroinflammatory target for further study as a potential therapeutic target to benefit recovery in acute SCI.

Sociodemographics Impact Competitiveness in the Neurosurgical Match: Survey Results.

BACKGROUND: The neurosurgical match involves selecting future neurosurgeons who will comprise the future national workforce, based on a competitive ranking process of applicants. We aimed to identify which sociodemographic and academic factors influence competitiveness and rank position in the match. METHODS: A Council of State Neurosurgical Societies (CSNS) survey was distributed to current U.S. neurosurgical residents. The primary outcome measure was self-reported rank position of matched program. Variables included sociodemographic and academic metrics. Fisher exact, logistic regression, and t tests were performed. RESULTS: Among the 72 respondents, median United States Medical Licensing Examination Step 1 score was 248, 34.7% were Alpha Omega Alpha inductees, 77.8% completed 1-3 sub-internship rotations, median number of publications was 5, and 13.9% had a Ph.D. Sociodemographic analysis demonstrated that 69.4% were male and 30.6% were female. Applicants with a home neurosurgery program or of female gender had statistically significantly higher odds of matching into a top 3 program on their rank list (odds ratio = 9 and odds ratio = 6, respectively). Female applicants exhibited similar mean, but less variance, compared with male respondents for United States Medical Licensing Examination Step 1 scores and number of publications. Respondents with a top 3 program match were more likely to agree that the home program supported their pursuance of neurosurgery. CONCLUSIONS: Two sociodemographic factors were independently associated with high match rank: presence of home neurosurgery program and female gender. Female respondents reported consistently strong academic metrics (similar mean, but less variance, compared with male respondents).

Factors affecting retirement and workforce attrition in neurosurgery: results of a Council of State Neurosurgical Societies national survey.

OBJECTIVE: By 2030, the US will not have enough neurosurgeons to meet the clinical needs of its citizens. Replacement of neurosurgeons due to attrition can take more than a decade, given the time-intensive training process. To identify potential workforce retention targets, the authors sought to identify factors that might impact neurosurgeons' retirement considerations. METHODS: The Council of State Neurosurgical Societies surveyed practicing AANS-registered neurosurgeons via email link to an online form with 25 factors that were ranked using a Likert scale of importance regarding retirement from the field (ranging from 1 for not important to 3 for very important). All participants were asked: "If you could afford it, would you retire today?" RESULTS: A total of 447 of 3200 neurosurgeons (14%) responded; 6% had been in practice for less than 5 years, 19% for 6-15 years, 57% for 16-30 years, and 18% for more than 30 years. Practice types included academic (18%), hospital employed (31%), independent with academic appointment (9%), and full independent practice (39%). The most common practice size was between 2 and 5 physicians (46%), with groups of 10 or more being the next most common (20%). Career satisfaction, income, and the needs of patients were rated as the most important factors keeping neurosurgeons in the workforce. Increasing regulatory burden, decreasing clinical autonomy, and the burden of insurance companies were the highest rated for factors important in considering retirement. Subgroup analysis by career stage, practice size, practice type, and geographic region revealed no significant difference in responses. When considering if they would retire now, 45% of respondents answered "yes." Subgroup analysis revealed that midcareer neurosurgeons (16-25 years in practice) were more likely to respond "yes" than those just entering their careers or in practice for more than 25 years (p = 0.03). This effect was confirmed in multivariate logistic regression (p = 0.04). These surgeons found professional satisfaction (p = 0.001), recertification requirements (p < 0.001), and maintaining high levels of income (p = 0.008) important to maintaining employment within the neurosurgical workforce. CONCLUSIONS: This study demonstrates that midcareer neurosurgeons may benefit from targeted retention efforts. This effort should focus on maximizing professional satisfaction and financial independence, while decreasing the regulatory burden associated with certification and insurance authorization. End-of-career surgeons should be surveyed to determine factors contributing to resilience and persistence within the neurosurgical workforce.

Trends in Racial and Ethnic Representation Among Neurosurgery Applicants and Residents: A Comparative Analysis of Procedural Specialties.

BACKGROUND: Diversity, equity, and inclusion within the healthcare workforce are conducive to providing culturally competent care. However, few existing studies have assessed the level of racial and ethnic diversity among resident physicians and residency applicants. Our objective was to provide a comparative analysis of the trends in racial and ethnic representation within different subspecialties in medicine. METHODS: Using data from the American Association of Medical Colleges and the Journal of the American Medical Association, we evaluated the racial and ethnic identification of residency applicants and current residents in 9 procedural-focused specialties from 2005 to 2019 and performed a descriptive analysis to compare the different levels of racial and ethnic diversity in these specialties. RESULTS: Among the specialties analyzed during the study period, neurosurgery had the greatest magnitude of differences between Black/African-American residency applicants and current residents. The percentage of Black/African-American applicants was 92% greater than that of Black/African-American residents (10% of applicants vs. 5.2% of residents). In contrast, the percentage of White neurosurgery residents was 17.6% greater than that of White neurosurgery applicants (53.9% of applicants vs. 63.4% of residents). Similar trends were noted in all the specialties evaluated. Obstetrics and gynecology demonstrated the least disparity between Black/African-American applicants and residents (13.7% of applicants vs. 10.2% of residents; 35.4% difference). Hispanic and Asian representation varied widely between specialties. CONCLUSIONS: Among the surveyed specialties, neurosurgery demonstrated the greatest disparity between the percentage of Black/African-American residency applicants and current residents. To further drive progress in this domain, we advocate for a series of initiatives designed to increase underrepresented minority participation in neurosurgery practice and scholarship.

An Evaluation of Neurosurgical Practices During the Coronavirus Disease 2019 Pandemic.

OBJECTIVE: We sought to understand how the coronavirus disease 2019 pandemic has affected the neurosurgical workforce. METHODS: We created a survey consisting of 22 questions to assess the respondent's operative experience, location, type of practice, subspecialty, changes in clinic and operative volumes, changes to staff, and changes to income since the pandemic began. The survey was distributed electronically to neurosurgeons throughout the United States and Puerto Rico. RESULTS: Of the 724 who opened the survey link, 457 completed the survey. The respondents were from throughout the United States and Puerto Rico and represented all practices types and subspecialties. Nearly all respondents reported hospital restrictions on elective surgeries. Most reported a decline in clinic and operative volume. Nearly 70% of respondents saw a decrease in the work hours of their ancillary providers, and almost one half (49.1%) of the respondents had had to downsize their practice staff, office assistants, nurses, schedulers, and other personnel. Overall, 43.6% of survey respondents had experienced a decline in income, and 27.4% expected a decline in income in the upcoming billing cycle. More senior neurosurgeons and those with a private practice, whether solo or as part of a group, were more likely to experience a decline in income as a result of the pandemic compared with their colleagues. CONCLUSION: The coronavirus disease 2019 pandemic will likely have a lasting effect on the practice of medicine. Our survey results have described the early effects on the neurosurgical workforce. Nearly all neurosurgeons experienced a significant decline in clinical volume, which led to many downstream effects. Ultimately, analysis of the effects of such a pervasive pandemic will allow the neurosurgical workforce to be better prepared for similar events in the future.

The Financial Impact of the COVID-19 Pandemic on Neurosurgery Practice in Spring 2020.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has changed health care delivery across the United States. Few analyses have specifically looked at quantifying the financial impact of the pandemic on practicing neurosurgeons. A survey analysis was performed to address this need. METHODS: A 19-question survey was distributed to practicing neurosurgeons in the United States and its territories. The questions evaluated respondents' assessments of changes in patient and procedural volume, salary and benefits, practice expenses, staffing, applications for government assistance, and stroke management. Responses were stratified by geographic region. RESULTS: The response rate was 5.1% (267/5224). Most respondents from each region noted a >50% decrease in clinic volume. Respondents from the Northeast observed a 76% decrease in procedure volume, which was significantly greater than that of other regions (P = 0.003). Northeast respondents were also significantly more likely to have been reassigned to nonneurosurgical clinical duties during the pandemic (P < 0.001). Most respondents also noted decreased salary and benefits but experienced no changes in overall practice expenses. Most respondents did not experience significant reductions in nursing or midlevel staffing. These trends were not significantly different between regions. CONCLUSIONS: The COVID-19 pandemic has led to decreases in patient and procedural volume and physician compensation despite stable practice expenses. Significantly more respondents in the Northeast region noted decreases in procedural volume and reassignment to nonneurosurgical COVID-related medical duties. Future analysis is necessary as the pandemic evolves and the long-term clinical and economic implications become clear.

Deficiency of telomerase activity aggravates the blood-brain barrier disruption and neuroinflammatory responses in a model of experimental stroke.

Epidemiology and genetic studies indicate that patients with telomere length shorter than average are at higher risk of dying from heart disease or stroke. Telomeres are located at the ends of eukaryotic chromosomes, which demonstrate progressive length reduction in most somatic cells during aging. The enzyme telomerase can compensate for telomere loss during cell replication. The present study sought to investigate the contribution of telomerase to stroke and blood-brain barrier (BBB) dysfunction. Telomerase reverse transcriptase knockout (TERT(-/-)) mice and littermate controls with normal TERT expression were subjected to a 24-hr permanent middle cerebral artery occlusion (pMCAO). The stroke outcomes were assessed in terms of neurological scores and infarct volumes. In addition, we evaluated oxidative stress, permeability across the BBB, and integrity of tight junctions in brain microvessels. Neurological testing revealed that TERT(-/-) mice showed enhanced deficits compared with controls. These changes were associated with a greater infarct volume. The expression of tight junction protein ZO-1 decreased markedly in ischemic hemispheres of TERT(-/-) mice. The brain microvessels of TERT(-/-) mice also were more susceptible to oxidative stress, revealing higher superoxide and lower glutathione levels compared with mice with normal TERT expression. Importantly, TERT deficiency potentiated the production of inflammatory mediators, such as tumor necrosis factor-alpha, interleukin-1 beta, and intercellular adhesion molecule-1, in the ischemic hemispheres of mice with pMCAO. Our study suggests that TERT deficiency can predispose to the development of stroke in an experimental model of this disease.

The Enforceability of Noncompete Clauses in the Medical Profession: A Review by the Workforce Committee and the Medicolegal Committee of the Council of State Neurosurgical Societies.

BACKGROUND: In both academic and private practice, noncompete clauses are common in many neurological surgery contracts. Noncompete agreements vary, depending on various factors, including the surgeon's subspecialty, location, and business-related considerations. Each individual state's law on contracts determines the extent to which noncompete clauses are enforceable. OBJECTIVE: To evaluate the disparate approaches of various states regarding the enforceability of these clauses and their components. METHODS: This review surveys several of the most populous states' law regarding noncompete clauses. This analysis includes an evaluation of state statutes and common law regarding noncompete clauses. It also relies on legal treatises and law review articles. RESULTS: The enforceability of the noncompete clause depends on the state in which the physician is employed. CONCLUSION: It is imperative that individuals understand the content of any noncompete clauses in their contract, as well the climate of the state in which they practice. The state's approach determines whether any part or all of the noncompete agreement is enforceable. A review by the Workforce Committee and the Medico-legal Committee of the Council of State Neurosurgical Societies (CSNS) provides explanation of the common elements in restrictive covenants or noncompete clauses and reviews the enforceability of these clauses.

Vessel microport technique for applications in cerebrovascular research.

Cerebrovascular research suffers from a lack of reliable methods with which to deliver exogenous substances effectively into the central nervous system (CNS) of small experimental animals. Here we describe a novel vessel microport surgical technique for a variety of cerebrovascular applications that is reproducible and well tolerated in mice. The procedure is based on the insertion of a vessel microport into the external carotid artery for substance delivery into the CNS via the internal carotid artery. The method results in selective substance delivery into the ipsilateral hemisphere. Other novel aspects of this surgical technique include the ability to perform multiple injections, study of conscious mice well removed from surgery, and lack of occlusion of the common or internal carotid artery that allows carotid flow to be maintained. The feasibility of this technique has been validated by infusion of HIV Tat protein to induce permeability of the blood-brain barrier and by implantation of tumor cells to establish a brain metastasis model. Thus, the described vessel microport technique can be employed in a variety of cerebrovascular research applications.

Factors associated with burnout among US neurosurgery residents: a nationwide survey.

OBJECTIVEExcessive dissatisfaction and stress among physicians can precipitate burnout, which results in diminished productivity, quality of care, and patient satisfaction and treatment adherence. Given the multiplicity of its harms and detriments to workforce retention and in light of the growing physician shortage, burnout has garnered much attention in recent years. Using a national survey, the authors formally evaluated burnout among neurosurgery trainees.METHODSAn 86-item questionnaire was disseminated to residents in the American Association of Neurological Surgeons database between June and November 2015. Questions evaluated personal and workplace stressors, mentorship, career satisfaction, and burnout. Burnout was assessed using the previously validated Maslach Burnout Inventory. Factors associated with burnout were determined using univariate and multivariate logistic regression.RESULTSThe response rate with completed surveys was 21% (346/1643). The majority of residents were male (78%), 26-35 years old (92%), in a stable relationship (70%), and without children (73%). Respondents were equally distributed across all residency years. Eighty-one percent of residents were satisfied with their career choice, although 41% had at some point given serious thought to quitting. The overall burnout rate was 67%. In the multivariate analysis, notable factors associated with burnout included inadequate operating room exposure (OR 7.57, p = 0.011), hostile faculty (OR 4.07, p = 0.008), and social stressors outside of work (OR 4.52, p = 0.008). Meaningful mentorship was protective against burnout in the multivariate regression models (OR 0.338, p = 0.031).CONCLUSIONSRates of burnout and career satisfaction are paradoxically high among neurosurgery trainees. While several factors were predictive of burnout, including inadequate operative exposure and social stressors, meaningful mentorship proved to be protective against burnout. The documented negative effects of burnout on patient care and health care economics necessitate further studies for potential solutions to curb its rise.

Gender differences in spinal cord injury are not estrogen-dependent.

Recent attention has been given to gender differences in neurotrauma, and the anecdotal suggestion is that females have better outcomes than males, suggesting that circulating levels of estrogen (E(2)) may be neuroprotective. In order to address this issue, both young adult male and ovariectomized female rats were subjected to a T10 spinal cord injury (SCI), and E2 levels were maintained at chronic, constant circulating levels. Animals were clinically evaluated for locomotor changes using the Basso-Beattie-Bresnahan (BBB) scoring system. Morphologic differences were evaluated with unbiased stereology. Data analysis failed to reveal any significant benefit for the E2 therapy in either males or females. We did find a non-estrogen-dependent difference between male and female rats in length of injury, and percent of spared tissue, with female outcomes more favorable. These results suggest that E(2) does not provide a viable therapy following SCI.

Effects of progesterone on experimental spinal cord injury.

Progesterone has been proposed to be protective to the central nervous system following injury. This study assessed progesterone supplementation in the setting of contusional spinal cord injury in male and female rats. Short-term (5 days of either 4 or 8 mg/kg progesterone) and long-term (14 days of either 8 or 16 mg/kg progesterone) therapy failed to show any significant alteration in locomotor functioning and injury morphometrics after 21 days. This study does not support progesterone as a potential therapeutic agent in spinal cord injury.

Anticipated Changes in Spine Practice with Advancing Center for Medicare and Medicaid Services-Required Changes.

In providing spinal care to neurosurgical patients, cost and quality metrics are areas of interest to many. The federal government has legislated changes mandated for Centers for Medicare and Medicaid Services-enrolled patient care. The ever-changing administrative and patient-care challenges and opportunities are explored in this article, highlighting the Medicare Access and CHIP (Children's Health Insurance Program) Reauthorization Act of 2015 (MACRA), in the context of the Affordable Care Act. Trends in contemporary spinal care, addressing bundling, patient satisfaction, and ambulatory surgical centers are featured.

Recurrent lumbar disc herniation.

Recurrent lumbar disc herniation is a common disease process. It has been noted to occur in 5 to 15% of cases surgically treated for primary lumbar disc herniation. Outcomes in one series approached those after the initial operations, although this is not the case in the experience of most surgeons. The removal of recurrent lumbar disc herniations requires meticulous surgical technique. Great care is taken to identify the osseous margins of the previous surgical site. Identification and dissection of scar from the dura mater is greatly aided with the use of a microscope.

Noninvasive evaluation of electrical stimulation impacts on muscle hemodynamics via integrating diffuse optical spectroscopies with muscle stimulator.

Technologies currently available for the monitoring of electrical stimulation (ES) in promoting blood circulation and tissue oxygenation are limited. This study integrated a muscle stimulator with a diffuse correlation spectroscopy (DCS) flow-oximeter to noninvasively quantify muscle blood flow and oxygenation responses during ES. Ten healthy subjects were tested using the integrated system. The muscle stimulator delivered biphasic electrical current to right leg quadriceps muscle, and a custom-made DCS flow-oximeter was used for simultaneous measurements of muscle blood flow and oxygenation in both legs. To minimize motion artifact of muscle fibers during ES, a novel gating algorithm was developed for data acquisition at the time when the muscle was relaxed. ES at 2, 10, and 50 Hz were applied for 20 min on each subject in three days sequentially. Results demonstrate that the 20-min ES at all frequencies promoted muscle blood flow significantly. However, only the ES at 10 Hz resulted in significant and persistent increases in oxy-hemoglobin concentration during and post ES. This pilot study supports the application of the integrated system to quantify tissue hemodynamic improvements for the optimization of ES treatment in patients suffering from diseases caused by poor blood circulation and low tissue oxygenation (e.g., pressure ulcer).

External neurolysis may result in early return of function in some muscle groups following brachial plexus surgery.

A retrospective chart review, of those individuals seen and operated on by the Multidisciplinary Brachial Plexus Clinic team at the University of Kentucky Chandler Medical Center, was undertaken to determine those individuals who had early return-of-function following surgery for BPI. Seven patients met our criteria, with four of them having substantial improvement of two or more points gained on the MRC rating scale, in one or more muscle groups within six to eight weeks after surgery. Those patients with return-of-function earlier than expected for axonal regrowth from nerve transfer or grafting, had evidence for continuity but no significant reinnervation before surgery in the muscle groups that improved. We theorize that this early improvement is related to a compression-induced dysfunction which inhibited reinnervation and was relieved by performing external neurolysis.

Melatonin-analog, beta-methyl-6-chloromelatonin, supplementation in spinal cord injury.

Spinal cord injury (SCI) is a devastating condition. Melatonin supplementation has been shown to lessen SCI, but its use has been limited by its side effect profile. In this work, rats underwent a moderate-to-severe contussional SCI with either placebo or beta-methyl-6-chloromelatonin, 10mg/kg or 100mg/kg supplementation. The 10mg/kg supplementation demonstrated benefit; the 100mg/kg dosage was limited by toxicity. This is the first work to assess a melatonin analog in SCI.

Proximal sciatic nerve intraneural ganglion cyst.

Intraneural ganglion cysts are nonneoplastic, mucinous cysts within the epineurium of peripheral nerves which usually involve the peroneal nerve at the knee. A 37-year-old female presented with progressive left buttock and posterior thigh pain. Magnetic resonance imaging revealed a sciatic nerve mass at the sacral notch which was subsequently revealed to be an intraneural ganglion cyst. An intraneural ganglion cyst confined to the proximal sciatic nerve has only been reported once prior to 2009.