Evaluating neurosurgical training: a national survey examining the British trainee experience.

PURPOSE: Neurosurgery training in the UK has undergone significant changes over the past few years, including the new competency-based curriculum and a reduction of elective operating due to the pandemic. We conducted a comprehensive survey to assess UK neurosurgical trainees' experiences and perceptions to develop targeted action plans. METHODS: An online anonymised survey was developed and distributed amongst the BNTA mailing list. Question types included 10-point Likert scales and free text options. Descriptive statistics, non-parametric testing of Likert scores, and Spearman's rank correlation were used to analyse responses. Pearson's chi-squared test was used for subgroup analysis of categorical data. RESULTS: A total of 75 trainees with a National Training Number (NTN) responded. Overall trainees feel they are well trained, well supported, and have caught up with training emerging out of COVID. Funding for training varied between deaneries. There is significant concern amongst trainees regarding the workforce crisis. This, as well as financial concerns are leading to more than a quarter of trainees considering quitting. Half of the trainees are considering going OOP. More than one third of the trainees and more than half of the female trainees are considering working Less Than Full Time (LTFT). Most important supportive mechanisms towards completion of training were social support, along with personal satisfaction from work. An independent mentoring scheme is a preferred additional support mechanism. CONCLUSIONS: Overall training experience for neurosurgery trainees in UK and Ireland was positive. There are significant concerns regarding the workforce crisis and costs of training, with a large proportion of neurosurgery trainees considering resigning. OOP and LTFT are popular means of becoming more competitive for consultant posts and to spend time with their families. Deanery experience, senior and peer support does, and will improve trainee experience and protect against attrition.

Perioperative visual loss and consent for adult spine surgery: a national survey of the practice amongst spine surgeons and anaesthetists†.

BACKGROUND: Perioperative Visual Loss (POVL) is a devastating complication for patients undergoing spine surgery. Consent process for POVL amongst spine surgeons and anaesthetist remains variable. The aim of this study is to evaluate their practice and views about it. METHODS: Two similar questionnaires were distributed to members of the Society of British Neurological Surgeons (SBNS), British Association of Spine Surgeons (BASS), and Neuroanaesthsia and Critical Care Society (NACCS). RESULTS: A total of 271 responses were received (SBNS/BASS n = 149, NACCS n = 122). Fewer surgeons considered POVL as a material risk for patients compared to the anaesthetists (57.7 versus 79.7%). Outpatient/pre-assessment clinics were considered as the optimal setting for discussing POVL by the majority of the clinicians (81.2 and 93.4%). POVL should be discussed by both specialists according to 75% of the anaesthetists. Estimated incidence of POVL was considered to be higher by the anaesthetists (0.03-0.2% by 63% of the anaesthetist versus 0.0001-0.004% by 57% of the surgeons). Twenty-three surgeons and 10 anaesthetists had a patient who suffered from POVL, which led to a change of practice in most of them. This questionnaire will lead to a change in practice/consent to 18.1% of the surgeons and 23.5% of the anaesthetists. CONCLUSIONS: Most of the surgeons and anaesthetist feel that POVL is a material risk that ideally needs to be firstly discussed before the day of surgery, by both specialties. However, a significant number of clinicians have an opposite view. A national guidance from respective societies should encourage POVL to be discussed routinely.

Spinal cord compression due to nucleus migration from Mobi-C total disc replacement.

Cervical disc replacement is an alternative option to an anterior cervical discectomy and fusion for cervical spine degenerative disease. We present the first reported case of a progressively worsening symptomatic spinal cord compression secondary to migration of the nucleus from a Mobi-C total disc replacement.

Retrieval analysis of an explanted Mobi-C cervical disc replacement: A case study.

Ex vivo analysis of artificial discs is essential to better understand their ability to replace degenerated intervertebral discs. The Mobi-C differs from some other contemporary disc designs in that it has a mobile polyethylene insert that is sandwiched between superior and inferior cobalt chromium endplates. While some studies claim the Mobi-C to have restored normal cervical spinal biomechanics, others have noted high levels of migration. Our objective was to contribute to this debate by, for the first time, analysing an explanted Mobi-C cervical disc which was removed due to worsening myelopathy at the nano and macro scales. Intraoperatively, the insert was found to have excessively migrated and it compressed the spinal cord. Roughness was measured as 0.016 ± 0.006 µm (Sa) and 0.055 ± 0.020 µm (Sa) for the superior and inferior plates, and 1.210 ± 0.154 µm (Sa) and 0.446 ± 0.083 µm (Sa) for the superior and inferior surfaces of the insert. Compared to unworn surfaces, the roughness increased for the superior and inferior plates and decreased for both surfaces of the insert. However, the only statistically significant change occurred on the articulating surface of the inferior plate (p = 0.04). At the nanoscale, valleys dominated the articulating surfaces. The superior plate had a burnished appearance whereas the inferior plate appeared matt. Impingement was observed on the endplates. The insert was severely damaged, burnished and had scratches. Additionally, subsurface whitening and internal cracking were observed on the insert.

Solid Component Volume as a Proxy to Identify Distinct Hemangioblastoma Populations.

BACKGROUND: Posterior fossa hemangioblastomas usually consist of a small solid nodule with a large cyst, while more rarely they present as a large solid mass with a small or absent cyst, which can be surgically challenging. We sought to investigate the potential existence of multiple distinct hemangioblastoma populations using tumor volumetric data as an indicator. METHODS: We conducted a retrospective review of surgically treated hemangioblastomas between 2005 and 2019 in our unit, including clinical notes, preoperative magnetic resonance imaging volumetric analysis of the solid component of the tumor, and pathology. Finite Gaussian mixture modeling was applied on the solid component volume dataset to identify potential underlying Gaussian distributions with their associated characteristics. Nonparametric Mann-Whitney U tests were used to investigate significance of differences (P < 0.05) in solid component volume and different variables (Von Hippel-Lindau disease, extent of resection, outcome). RESULTS: A total of 68 consecutive patients were included. Solid component volumes followed a multimodal distribution (median = 1287 mm3, interquartile range of 3428 mm3). The best-fit finite Gaussian mixture modeling model identified 3 statistically significant different (P = 0.001) potential mixture components: X1 (219 ± 187 mm3), X2 (2686 ± 1299 mm3), and X3 (10,800 ± 5514 mm3). The second-best model detected 2 significantly different (P = 9.99e-08) mixture components Y1 (222 ± 189 mm3) and Y2 (5391 ± 5094 mm3). A significant difference in solid component volume was found between patients with favorable and unfavorable outcome (P = 0.002). CONCLUSIONS: This study has shown preliminary evidence that large solid hemangioblastomas may constitute a completely distinct population, rather than a variant of one large group of hemangioblastomas.

Does the duration of symptoms influence outcome in patients with sciatica undergoing micro-discectomy and decompressions?

BACKGROUND: Early surgical treatment for back and leg pain secondary to disc herniation has been associated with very good outcomes. However, there are conflicting data on the role of surgical treatment in case of prolonged radicular symptomatology. PURPOSE: We aimed to evaluate whether the duration of symptoms at presentation affects the subjective outcome. STUDY DESIGN/SETTING: This is a retrospective review of prospectively collected data from a single surgeon including micro-discectomies and lateral recess decompressions in patients younger than 60 years old using patient medical notes, radiology imaging, operation notes, and Patient Reported Outcome Measures (PROMS) including Oswestry Disability Index (ODI), visual analogue scale for back pain and leg pain (VAS-BP and VAS-LP). The final follow-up was carried out through postal questionnaire or telephone consultation. METHODS: Demographic information, duration of symptoms, type and incidence of complications, length of hospital stay, and follow-up were analyzed. Data were categorized into four subgroups: symptoms 0≥6 months, 6 months≥1 year, 1 year≥2 years, and >2 years. A clinically significant result was an average improvement of 2 or more points in the VAS and of 20% and over in the ODI. The level of statistical significance was <0.05%. RESULTS: A total number of 107 patients who underwent 109 operations were included. The level of surgery was L5/S1 (50), L4/L5 (43), L3/L4 (3), L2/L3 (2), and two levels (11). The mean improvement was from 0 to ≤6 months (VAS-LP 5.21±2.81, VAS-BP 3.04±3.15, ODI 35.26±19.25), 6 months to ≤1 year (VAS-LP 4.73±2.61, VAS-BP 3.30±3.05, ODI 26.92±19.49), 1 year to ≤2 years (VAS-LP 3.78±3.68, VAS-BP 3.00±2.78, ODI 19.03±20.24), and >2 years (VAS-LP 4.77±3.61, VAS-BP 3.54±3.43, ODI 28.36±20.93). The length of hospital stay and complication rate was comparable between groups. Average follow-up was 15.69 months. CONCLUSIONS: Our study showed significant improvement in patients with symptoms beyond 1 as well as 2 years since onset, and surgery is a viable option in selected patients.

Cerebellar mutism.

Mutism of cerebellar origin is a well-described clinical entity that complicates operations for posterior fossa tumors, especially in children. This review focuses on the current understanding of principal pathophysiological aspects and risk factors, epidemiology, clinical characteristics, treatment strategies, and outcome considerations. The PubMed database was searched using the term cerebellar mutism and relevant definitions to identify publications in the English-language literature. Pertinent publications were selected from the reference lists of the previously identified articles. Over the last few years an increasing number of prospective studies and reviews have provided valuable information regarding the cerebellar mutism syndrome. Importantly, the clarification of principal terminology that surrounds the wide clinical spectrum of the syndrome results in more focused research and more effective identification of this entity. In children who undergo surgery for medulloblastoma the incidence of cerebellar mutism syndrome was reported to be 24%, and significant risk factors so far are brainstem involvement and midline location of the tumor. The dentate-thalamo-cortical tracts and lesions that affect their integrity are considered significant pathophysiological issues, especially the tract that originates in the right cerebellar hemisphere. Moderate and severe forms of the cerebellar mutism syndrome are the most frequent types during the initial presentation, and the overall neurocognitive outcome is not as favorable as thought in the earlier publications. Advanced neuroimaging techniques could contribute to identification of high-risk patients preoperatively and allow for more effective surgical planning that should focus on maximal tumor resection with minimal risk to important neural structures. Properly designed multicenter trials are needed to provide stronger evidence regarding effective prevention of cerebellar mutism and the best therapeutic approaches for such patients with a combination of pharmacological agents and multidisciplinary speech and behavior augmentation.

Oxidative status in ICU patients with septic shock.

The aim of this pilot study was to investigate variability of oxidative stress during sepsis evolution. ICU patients with the diagnosis of septic shock were included. Thiobarbituric-acid reactive substances, total antioxidant capacity, protein carbonyls in plasma, reduced, oxidized glutathione and catalase activity in erythrocyte lysate were assessed in the 1st, 3rd, 5th and 8th day after sepsis appearance. A total of 17 patients were divided in two groups: survivors (n=7) and non-survivors (n=10). APACHE II was 11.5 ± 5.4 and 19.9 ± 4.97 in survivors and non-survivors respectively (p=0.005), while mean age and SOFA score at sepsis diagnosis, were similar between the two groups. GSH levels, catalase activity and protein carbonyls presented significant different course in time between survivors and non-survivors (p<0.05). Catalase activity was significantly higher in survivors (238.8 ± 51.5) than non-survivors (166.4 ± 40.2; p=0.005), while protein carbonyls levels were significantly lower in survivors (0.32 ± 0.09) than non-survivors (0.48 ± 0.16; p=0.036) on the 1st day. Yet, non-survivors exhibited a declining course in GSH levels during time, while GSH levels were maintained in survivors. Conclusively, a longstanding antioxidant deficiency in non-surviving patients was noted. This phenomenon was clearly prominent in patients' erythrocytes.