A guide to interpreting systematic reviews and meta-analyses in neurosurgery and surgery.

INTRODUCTION: Systematic reviews (SRs) and meta-analyses (MAs) are methods of data analysis used to synthesize information presented in multiple publications on the same topic. A thorough understanding of the steps involved in conducting this type of research and approaches to data analysis is critical for appropriate understanding, interpretation, and application of the findings of these reviews. METHODS: We reviewed reference texts in clinical neuroepidemiology, neurostatistics and research methods and other previously related articles on meta-analyses (MAs) in surgery. Based on existing theories and models and our cumulative years of expertise in conducting MAs, we have synthesized and presented a detailed pragmatic approach to interpreting MAs in Neurosurgery. RESULTS: Herein we have briefly defined SRs sand MAs and related terminologies, succinctly outlined the essential steps to conduct and critically appraise SRs and MAs. A practical approach to interpreting MAs for neurosurgeons is described in details. Based on summary outcome measures, we have used hypothetical examples to illustrate the Interpretation of the three commonest types of MAs in neurosurgery: MAs of Binary Outcome Measures (Pairwise MAs), MAs of proportions and MAs of Continuous Variables. Furthermore, we have elucidated on the concepts of heterogeneity, modeling, certainty, and bias essential for the robust and transparent interpretation of MAs. The basics for the Interpretation of Forest plots, the preferred graphical display of data in MAs are summarized. Additionally, a condensation of the assessment of the overall quality of methodology and reporting of MA and the applicability of evidence to patient care is presented. CONCLUSION: There is a paucity of pragmatic guides to appraise MAs for surgeons who are non-statisticians. This article serves as a detailed guide for the interpretation of systematic reviews and meta-analyses with examples of applications for clinical neurosurgeons.

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

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

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

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

Observational Studies in Neurosurgery: Structure, Functioning, and Uses.

INTRODUCTION: Although randomized interventional studies are the gold standard of clinical study designs, they are not always feasible or necessary. In such cases, observational studies can bring insights into critical questions while minimizing harm and cost. There are numerous observational study designs, each with strengths and demerits. Unfortunately, it is not uncommon for observational study designs to be poorly designed or reported. In this article, the authors discuss similarities and differences between observational study designs, their application, and tenets of good use and proper reporting focusing on neurosurgery. METHODS: The authors illustrated neurosurgical case scenarios to describe case reports, case series, and cohort, cross-sectional, and case-control studies. The study design definitions and applications are taken from seminal research methodology readings and updated observational study reporting guidelines. RESULTS: The authors have given a succinct account of the structure, functioning, and uses of common observational study designs in Neurosurgery. Specifically, they discussed the concepts of study direction, temporal sequence, advantages, and disadvantages. Also, they highlighted the differences between case reports and case series; case series and descriptive cohort studies; and cohort and case-control studies. Also, they discussed their impacts on internal validity, external validity, and relevance. CONCLUSION: This paper disambiguates widely held misconceptions on the different observational study designs. In addition, it uses case-based scenarios to facilitate comprehension and relevance to the academic neurosurgery audience.

Vulnerability of African Neurosurgery to Predatory Journals: An Electronic Survey of Aspiring Neurosurgeons, Residents, and Consultants.

BACKGROUND: Predatory journals (PJs) publish research with little to no rigorous peer review in exchange for money. It is unclear what proportion of researchers is vulnerable to PJs and which factors are associated with vulnerability. The aim of this study was to evaluate the vulnerability of African neurosurgery researchers to PJs and identify their correlates. METHODS: A 3-part electronic survey in English and French versions was distributed via social media to African consultants and trainees from November 1 to December 1, 2021. Bivariable relationships were evaluated with χ2 test, Mann-Whitney U test, Spearman ρ correlation, odds ratios, and 95% confidence intervals. A P value < 0.05 was considered statistically significant. RESULTS: There were 101 respondents to the survey (response rate 56.1%). Respondents had mean age of 34.9 years, 82.2% were male (n = 83), 38.6% were consultant neurosurgeons (n = 39), and 33.7% were from Central Africa (n = 34). Of respondents, 66 had published ≥ 1 articles in the past, and 13 had published at least 1 article in a PJ. A PJ had contacted 34 respondents via e-mail, and 8 respondents had reviewed articles for a PJ. The Think. Check. Submit initiative and Beall's list were familiar to 19 and 13 respondents, respectively. Publication in PJs was correlated with the respondent's age (R = 0.23, P = 0.02) and total scholarly output (R = 0.38, P < 0.01). CONCLUSIONS: Young African neurosurgery researchers are vulnerable to PJs primarily because they are not familiar with the concept of PJs or how to identify them.

Landscape, Presentation, and Characteristics of Brain Gliomas in Zimbabwe.

INTRODUCTION: Gliomas are tumors of the supporting cells of the central nervous system. They have great heterogeneity in their clinical and pathological features as well as prognosis. There is paucity of glioma epidemiology data in Zimbabwe. We carried out a study to determine the landscape, presentation, and characteristics of brain gliomas in Zimbabwe. MATERIALS AND METHODS: A prospective cross-sectional study was conducted in Zimbabwe over a 2 years period to determine descriptive epidemiological data with regards to demographic distribution, presentation, and tumor characteristics. Consecutive patients from across the country with brain gliomas were recruited in the study. RESULTS: A total of 112 brain tumors were diagnosed histologically. Of these 43.8% (n = 49) were gliomas and hence recruited in the study. The mean age of study participants was 40.3 years (standard deviation = 23.1 years), range 3-83 years. Male to female ratio (M:F) was 1:1. The study population consisted of 14% caucasians (n = 7), 83.7% black (n = 41), and 2% (n = 1) were of mixed race. Eighty-six percent (n = 42) of participants were from urban areas. The most common presenting complaint was headache in 87.8% (n = 43). The majority (61.2%) presented with a Karnofsky score ≥70%. Astrocytomas were the most common gliomas constituting 57.1% (n = 28), followed by ependymomas and oligodendrogliomas being 8.1% (n = 4) each. There was no statistical difference in the hemisphere of the brain involved (P = 0.475). Eight percent of the population were HIV positive (n = 4). Age above 60 years has an adjusted odds ratio of 13 for presenting with high-grade tumors. CONCLUSION: There is a disproportionately high number of gliomas among Caucasians, urban dwellers, and those gainfully employed. The prevalence of HIV in glioma patients is less than that of the general population.

Truncal complex regional pain syndrome, myth or reality: Case report.

INTRODUCTION: Complex regional pain syndrome (CRPS) is an under diagonised, chronic pain condition commonly described occurring in the extremities. Its occurrence in the trunk is rarely reported and is thought by some to be non existent. CASE PRESENTATION: We report an unusual case of trunkul CRPS post appendectomy which presented with debilitating pain and review relevant literature. DISCUSSION AND CONCLUSION: We recommend that subsequent descriptions and diagnostic criteria should include the trunk as a site of occurrence of CRPS and not just the extremities. This will help reduce under diagnosis of this important condition.

The Impact of COVID-19 on Neurosurgical Services in Africa.

INTRODUCTION: COVID-19 has affected the global provision of neurosurgical services. We sought to review the impact of COVID-19 on the neurosurgical services in Africa. METHODS: A cross-sectional survey was distributed to African neurosurgeons seeking to review demographics, national and neurosurgical preparedness, and change in clinical services in April 2020. RESULTS: A total of 316 responses from 42 countries were received. Of these, 81.6% of respondents were male and 79.11% were under the age of 45 years. In our sample, 123 (38.92%) respondents were in training. Most (94.3%) respondents stated they had COVID-19 cases reported in their country as of April 2020. Only 31 (41.50%) had received training on managing COVID-19. A total of 173 (54.70%) respondents were not performing elective surgery. There was a deficit in the provision of personal protective equipment (PPE): surgical masks (90.80%), gloves (84.80%), N95 masks (50.80%), and shoe covers (49.10%). Health ministry (80.40%), World Health Organization (74.50%), and journal papers (41.40%) were the most common sources of information on COVID-19. A total of 43.60% had a neurosurgeon in the COVID-19 preparedness team; 59.8% were concerned they may contract COVID-19 at work with a further 25.90% worried they may infect their family. Mental stress as a result of COVID-19 was reported by 14.20% of respondents. As of April 2020, 73.40% had no change in their income. CONCLUSIONS: Most African countries have a national COVID-19 policy response plan that is not always fully suited to the local neurosurgery services. There is an ongoing need for PPE and training for COVID-19 preparedness. There has been a reduction in clinical activities both in clinic and surgeries undertaken.

A Continental Survey on the Impact of COVID-19 on Neurosurgical Training in Africa.

BACKGROUND: Containment measures for COVID-19 have affected surgical training globally. We sought to assess how neurosurgical training has been affected across Africa in April 2020. METHODS: A cross-sectional survey was distributed to African Neurosurgical trainees seeking to review demographics and effects of COVID on training. RESULTS: A total of 123 neurosurgery trainees responded from 23 African countries and a further 6 were abroad. A total of 91.80% were men, and 96.70% were training in public institutions. Only 41% had received training in COVID-19 with 61.79% worried that they would contract COVID-19 while performing their clinical duties. There was a marked reduction in clinical activities including a median reduction of elective surgery (-80%), clinics (-83%), and emergency surgery (-38.50%). A total of 23.58% of residents did not receive a formal salary, with 50% on less than $1000 USD gross per month. CONCLUSIONS: This is the first continental survey of neurosurgery trainees in Africa. COVID-19 has significantly affected clinical and learning opportunities. There are concerns of the long-term effects on their training activities for an uncertain period of time during this pandemic. Although there has been a global increase in e-learning, there is need to evaluate if this is accessible to all trainees.

Antimicrobial effects of craniopharyngioma cystic fluid.

BACKGROUND: Tumours are known to increase the risk of infections, especially those occurring in the central nervous system where insertion of surgical hardware/shunts such as in craniopharyngiomas may be required. However, infections are surprisingly scarce in craniopharyngioma cases. In this study, we explored the possibility of antimicrobial effects of craniopharyngioma cystic fluid. METHODS: The antibacterial effect of craniopharyngioma cystic fluid samples against selected human pathogens: Escherichia. coli, S. aureus and S. pneumoniae were determined using the agar disc diffusion method. Streptomycin and ampicillin were used as controls. The test organisms were cultured in Mueller-Hinton broth overnight at 37 °C. McFarland standard was used as a reference to adjust the inoculum size of each test organism to a concentration of 1 × 106 CFU/ml using sterile broth. RESULTS: The craniopharyngioma cystic fluid inhibited growth of Gram-positive bacteria S. aureus and S. pneumoniae, but not the Gram-negative bacteria, E. coli. The samples showed the highest zones of S. pneumoniae growth inhibition of up to 20.0 ± 1.0 mm compared with 18.0 ± 1.0 mm of streptomycin and 9.0 ± 0.0 mm of ampicillin. CONCLUSION: Craniopharyngioma cystic fluid showed significant antibacterial properties against Gram-positive bacteria. This novel finding has implications in the way we view infections in craniopharyngioma patients. More studies need to be carried out to further elucidate this unique finding and possibly exploit these antimicrobial properties.

Towards zero infection for ventriculoperitoneal shunt insertion in resource-limited settings: a multicenter prospective cohort study.

INTRODUCTION: Shunting for hydrocephalus can lead to improvement in the quality of life although the latter has been subdued by complications like shunt infection. Established protocols have contributed to the reduction of ventriculoperitoneal shunt (VPS) infections. Previously, we retrospectively demonstrated a low infection rate despite some of the protocol recommendations not being implemented. The aim of this study was to prospectively establish the incidence of shunt infection in the early post-shunt period following our protocol and elucidate on associated risk factors. PATIENTS AND METHODS: A multicenter prospective descriptive cohort study of consecutive 209 under-5 children requiring VPS for hydrocephalus was conducted between January 2013 and November 2018. An innovative protocol insisting on intermittent application of povidone-iodine on the skin during the operation was implemented. The patients were followed-up for 3 months post-surgery. RESULTS: Included were 211 VPS procedures performed on 209 children. The median age was 9 months and 84 were males. Hydrocephalus was non-communicative in 72.0% and aqueductal stenosis was its most frequent cause (84.9%). Most surgeries were performed in the morning (90.5%), electively (95.3%), and for the first time (91%). The median duration of surgery was 65 min. Shunt infection rate was 1.9% (n = 4) (95% CI 0.7 to 5.0%) per procedure. CONCLUSION: The observed infection rate was low. This suggests that the protocol followed captured the most critical components necessary to ensure low infection rates and that simple measures implemented in economically challenged environments may achieve internationally acceptable infection rates.

An unusual presentation of bobble-head doll syndrome in a patient with hydranencephaly and Chiari 3 malformation.

Bobble-head doll syndrome is a rare movement disorder that is usually associated with lesions involving the third ventricle. It is characterised by stereotypical rhythmic up-and-down or side-to-side head movements. The pathophysiology and anatomical basis for this unusual manifestation is still a subject of intense scrutiny. The syndrome has never been described in a patient with both hydranencephaly and Chiari type 3 malformation. We describe a 2-year-old female patient who presented with congenital hydrocephalus, an occipital encephalocele and rhythmic bobbling of the head. Imaging investigation revealed a Chiari type 3 malformation and hydranencephaly. The patient was taken to theatre for a ventriculoperitoneal shunt insertion, and at day 3 post operatively, the patient had a markedly decreased head circumference and a decrease in the frequency of the bobbling of the head. A further review at 2 weeks showed that the bobbling of the head had ceased. Although the pathophysiology of bobble-head doll syndrome is yet to be fully understood, there has been postulation of either a third ventricular enlargement or a cerebellar dysfunction to explain bobble-head doll syndrome. Our case illustrates that the pathophysiology is most likely multifactorial as illustrated by the fact that by just addressing the high intracranial pressure with a shunt was sufficient to treat the condition.

Prevalence of human immunodeficiency virus infection in brain glioma patients: Is the virus protective from gliomas?

BACKGROUND: Human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) is associated with an increased prevalence of some malignancies. However, some observational studies have revealed an ever-decreasing prevalence of HIV in glioma patients. The relationship between HIV and brain gliomas has not been well established. METHODS: A cross-sectional study was carried out in sub-Sahara Africa, a high HIV prevalence setting, to determine the prevalence of HIV among all glioma patients over a 2-year period. RESULTS: A markedly reduced prevalence of HIV was found in glioma patients (8.3%) in comparison to the general population (14.3%). The presumably "antiglioma effect" of HIV and/or its treatment resulted in a 42% decrease in glioma occurrence in HIV positive patients compared to HIV negative individuals. Age and sex-adjusted prevalence were also lower among glioma patients with the protective effect observed more in younger patients and female sex. CONCLUSION: Our results corroborate the protective effect of HIV positivity vis-à -vis gliomas. This "antiglioma effect" could be attributed to either the HIV, its treatment, or both. Future studies focused on this "effect" may help unveil better preventative and possible therapeutic avenues for gliomas.

Misclassification of Case-Control Studies in Neurosurgery and Proposed Solutions.

OBJECTIVE: Case-control studies (CCS) and cohort studies (CS) are common research designs in neurosurgery. But the term case-control study is frequently misused in the neurosurgical literature, with many articles reported as CCS, even although their methodology does not respect the basic components of a CCS. We sought to estimate the extent of these discrepancies in neurosurgical literature, explore factors contributing to mislabeling, and shed some light on study design reporting. METHODS: We identified 31 top-ranking pure neurosurgical journals and searched them for articles reported as CCS, either in the title or in the abstract. The articles were read to determine if they really were CCS according to STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines. Article assessment was conducted in duplicate (agreement [κ statistics] = 99.82%). RESULTS: Two hundred and twenty-four articles met our inclusion criteria, 133 of which (59.38%) correctly labeled the case-control design, whereas 91 (40.62%) misclassified this study design. Cohort studies (CS) were the most common design mislabeled as case-control studies in 76 articles (33.93%), 57 of which (25.45%) were retrospective CS. The mislabeling of CCS impairs the appropriate indexing, classification, and sorting of evidence. Mislabeling CS for CCS leads to a downgrading of evidence as CS represent the highest level of evidence for observational studies. Odds ratios instead of relative risk are reported for these studies, resulting in a distortion of the measurement of the effect size, compounded when these are summarized in systematic reviews and pooled in meta-analyses. CONCLUSIONS: Many studies reported as CCS are not true CCS. Reporting guidelines should include items that ensure that studies are labeled correctly. STROBE guidelines should be implemented in assessment of observational studies. Researchers in neurosurgery need better training in research methods and terminology. We also recommend accrued vigilance from reviewers and editors.

Parieto-temporal pleomorphic xanthoastrocytoma in a black African child.

Pleomorphic xanthoastrocytoma (PXA) is a rare cerebral tumor, accounting for <1% of all astrocytic neoplasms. PXA, usually, has a favorable prognosis in spite of what might be suggested from the ominous microscopic appearance. There is no literature immediately available on the black population for this tumor. Management is by surgical resection. The ideal is gross total resection, which offers an excellent prognosis. This disease condition has not been reported in the black population. The following is a presentation of a case report in a black African girl, followed by a review of the literature.

Spontaneous chronic subdural hematomas in human immunodeficiency virus-infected patients with normal platelet count and no appreciable brain atrophy: Two case reports and review of literature.

BACKGROUND: Chronic subdural hematomas (CSDHs) usually occur in elderly patients following minor head trauma. Their occurrence is usually linked to cerebral atrophy secondary to alcohol, old age, or human immunodeficiency virus (HIV) infection. Spontaneous CSDHs have also been documented but are rare. They are usually caused by coagulopathies and various pathologies resulting in intracranial hypotension. CASES: We have observed a number of spontaneous CSDHs in HIV patients with normal platelet counts and no appreciable cerebral atrophy possibly caused by platelet dysfunction, hence we report about two such cases. To the best of our knowledge, no such cases have been reported in literature before. CONCLUSION: It is important to include CSDHs in the differential diagnosis of HIV patients presenting with neurological deficits even without a history of trauma.

Capillary hemangioma in the superior sagittal sinus as a rare cause of intracranial hypertension in a child: case report.

OBJECTIVE AND IMPORTANCE: The etiological factors involved in idiopathic intracranial hypertension are not easy to identify. This case of idiopathic intracranial hypertension was associated with a capillary hemangioma growing in the lumen of the superior sagittal sinus. CLINICAL PRESENTATION: A 10-year-old girl had experienced progressive headaches and abdominal pain. Fundoscopic examination disclosed bilateral papilledema and high intrathecal pressure, suggesting idiopathic intracranial hypertension. Magnetic resonance imaging, including magnetic resonance angiography as well as digital angiography, revealed a 3-cm mass protruding into the superior sagittal sinus lumen above the torcular. INTERVENTION: A capillary hemangioma attached to the internal dural wall of the sagittal sinus lumen was microsurgically removed. The symptoms resolved in several days and no additional treatment was required. CONCLUSION: A tumor growing into a venous sinus is a rare cause of venous outflow impairment and may generate the clinical signs of idiopathic intracranial hypertension. This case emphasizes the importance of multiple complementary imaging modalities and the efficacy of a direct surgical approach, which allowed resolution of symptoms.

The surgeon and human immunodeficiency virus.

The moral dilemmas faced by surgeons worldwide who treat patients infected with the human immunodeficiency virus (HIV) can be viewed against the background of experience in sub-Saharan countries, where the community prevalence is in excess of 25% (90% of hospital inpatients). When seeking consent for an HIV test before surgery, frank communication regarding the surgeons' perspective of risks to themselves and the patient is helpful. When consent for a test must be obtained from a substitute decision-maker, the surgeon should consider if the patient would want the decision-maker to know the result. Understanding the natural history of HIV in the surgical setting can help deal with the uncertainties encountered and should be a research priority for developing countries. International professional organizations are useful platforms for the exchange of ideas when surgeons encounter uncertainty by increasing access to journals and creating opportunities for discussion. Although supervisory bodies in some parts of the world prevent HIV-infected surgeons from putting patients at risk by offering surgery, the withdrawal of their services in developing countries can cause more harm than good. Surgeons in that position may be entitled to offer surgery but only with full disclosure of the risk of HIV infection to the patient. The decision-making process known as "accountability for reasonableness" allows surgeons to determine fairness, legitimacy, and acceptability when making resource allocation decisions involving patients with HIV.