Functional Outcomes of Primary Hemiarthroplasty for Unstable Intertrochanteric Fractures in the Elderly: A Prospective Observational Study.

Background and objective Intertrochanteric fractures pose a growing healthcare challenge among the elderly, demanding effective management strategies. This study addressed the rising incidence of hip fractures, emphasizing the complications associated with traditional nonsurgical approaches. It aimed to explore postoperative functional outcomes and complications associated with primary hemiarthroplasty as an alternative to internal fixation for unstable intertrochanteric fractures in the elderly. Materials and methods This study included 20 elderly patients undergoing hemiarthroplasty for unstable intertrochanteric fractures. It evaluated key variables such as patient demographics, comorbidities, fracture characteristics, surgical approach, and postoperative metrics. To perform hemiarthroplasty, we utilized a nonmodular bipolar prosthesis with cement. Postoperative follow-up included an assessment of clinical and radiological parameters, focusing on outcomes and complications. Results The mean age of the participants was 71.65 years; it was found that a significant segment of the participants (n=9, 45%) did not have any comorbidities. The surgical outcomes were characterized by minimal blood loss (275 ± 57.35 ml), short hospital stays (6.55± 1.95 days), and satisfactory operative durations (80.25 ± 10.19 minutes). Additionally, 14 (70%) patients did not require blood transfusions. After the surgery, complications were minimal, and there were no cases of deep wound complications, prosthesis dislocations, or deep vein thrombosis. The Harris Hip Scores reflected favorable outcomes in 14 cases (72.7%), with good or excellent hip scores. Conclusions Our findings revealed that primary hemiarthroplasty is a reliable and effective strategy for managing unstable intertrochanteric fractures in the elderly, providing stable joints and acceptable complication rates. Early mobilization, facilitated by hemiarthroplasty, mitigates postoperative complications, making it a viable alternative for elderly patients.

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).

A Systematic Review of the State of Neurosurgical Disparities Research: Past, Present, and Future.

BACKGROUND: The social determinants of health, which influence healthcare access, patient outcomes, and population-level burden of disease, contribute to health disparities experienced by marginalized patient populations. In the present study, we sought to evaluate the landscape of health disparities research within neurosurgery. METHODS: Embase, Ovid-MEDLINE, Scopus, Web of Science, Cochrane Library, and ProQuest Dissertations databases were queried for original research on health disparities regarding access to, outcomes of, and/or postoperative management after neurosurgical procedures in the United States. RESULTS: Of 883 studies screened, 196 were included, of which 144 had a neurosurgery-affiliated author. We found a significant increase in the number of neurosurgical disparities reports beginning in 2010, with only 10 studies reported before 2010. Of the included studies, 3.1% used prospective methods and 63.8% used data from national registries. The disparities analyzed were racial/ethnic (79.6%), economic/socioeconomic (53.6%), gender (18.9%), and disabled populations (0.5%), with 40.1% analyzing multiple or intersecting disparities. Of the included reports, 96.9% were in phase 1 (detecting phase of disparities research), with a few studies in phase 2 (understanding phase), and none in phase 3 (reducing phase). The spine was the most prevalent subspecialty evaluated (34.2%), followed by neuro-oncology (19.9%), cerebrovascular (16.3%), pediatrics (10.7%), functional (9.2%), general neurosurgery (5.1%), and trauma (4.1%). Senior authors with a neurosurgical affiliation accounted for 79.2% of the reports, 93% of whom were academically affiliated. CONCLUSIONS: Although a recent increase has occurred in neurosurgical disparities research within the past decade, most studies were limited to the detection of disparities without understanding or evaluating any interventions for a reduction in disparities. Future research in neurosurgical disparities should incorporate the latter 2 factors to reduce disparities and improve outcomes for all patients.

Pupillary light reflex measured with quantitative pupillometry has low sensitivity and high specificity for predicting neuroworsening after traumatic brain injury.

BACKGROUND: Triage and neurological assessment of the 1.7 million traumatic brain injuries occurring annually is often done by nurse practitioners and physician assistants in the emergency department. Subjective assessments, such as the neurological examination that includes evaluation of the pupillary light reflex (PLR), can contain bias. Quantitative pupillometry (QP) standardizes and objectifies the PLR examination. Additional data are needed to determine whether QP can predict neurological changes in a traumatic brain injury (TBI) patient. PURPOSE: This study examines the effectiveness of QP in predicting neurological decline within 24 hours of admission following acute TBI. METHODOLOGY: This prospective, observational, clinical trial used pragmatic sampling to assess PLR in TBI patients using QP within 24 hours of ED admission. Chi-square analysis was used to determine change in patient status, through Glasgow Coma Scale (GCS), at baseline and within 24 hours of admission, to the QP. RESULTS: There were 95 participants included in the analysis; of whom 35 experienced neuroworsening, defined by change in GCS of >2 within the first 24 hours of admission. There was a significant association between an abnormal Neurological Pupil index (NPi), defined as NPi of <3, and neuroworsening (p < .0001). The sensitivity (51.43%) and specificity (91.67%) of abnormal NPi in predicting neuroworsening were varied. CONCLUSION: There is a strong association between abnormal NPi and neuroworsening in the sample of TBI patients with high specificity and moderate sensitivity. IMPLICATIONS: NPi may be an early indicator of neurological changes within 24 hours of ED admission in patients with TBI.

Current Trends in Subspecialty Fellowship Training for 1691 Academic Neurological Surgeons.

OBJECTIVE: Neurosurgical subspecialty fellowship training has become increasingly popular in recent decades. However, few studies have evaluated recent trends in postgraduate subspecialty education. This study aims to provide a detailed cross-sectional analysis of subspecialty fellowship training completion trends and demographics among U.S. academic neurosurgeons. METHODS: Academic clinical faculty (M.D. or D.O.) teaching at accredited neurosurgery programs were included. Demographic, career, and fellowship data were collected from departmental physician profiles and the American Association of Neurological Surgeons (AANS) membership database. Relative citation ratio scores were retrieved using the National Institutes of Health iCite tool. RESULTS: This study included 1691 surgeons (1756 fellowships) from 125 institutions. The majority (79.13%) reported fellowship training. Fellowship completion was more common among recent graduates (residency year >2000), as was training in multiple subspecialties (P < 0.0001). Spine was the most popular subspecialty (16.04%), followed by pediatrics (11.18%), and cerebrovascular (9.46%). The least common were trauma/critical care (2.52%) and peripheral nerve (1.26%). Spine, neuroradiology, and endovascular subspecialties grew in popularity over time. Pediatrics and spine were the most popular for females and males, respectively. Epilepsy and cerebrovascular had the most full professors, while endovascular and spine had the most assistant professors. Stereotactic/functional and epilepsy had the most Ph.Ds. Fellowship training correlated with higher weighted, but not mean, relative citation ratio scores among associate (P = 0.002) and full professors (P = 0.005). CONCLUSIONS: There is an emerging proclivity for additional fellowship training among young neurosurgeons, often in multiple subspecialties. These findings are intended to help guide professional decision-making and optimize the delivery of postgraduate education.

Back to basal: contemporary cerebrovascular cohort study of the supratentorial-infraoccipital approach.

OBJECTIVE: The objective of this paper was to assess applications of the supratentorial-infraoccipital (STIO) approach for cerebrovascular neurosurgery. METHODS: The authors conducted a cohort study of all consecutive cases in which the STIO approach was used during the study period, December 1995 to January 2021, as well as a systematic review of the literature. RESULTS: Twenty-five cerebrovascular cases were identified in which the STIO approach was used. Diagnoses included arteriovenous malformation (n = 15), cerebral cavernous malformation (n = 5), arteriovenous fistula (n = 4), and aneurysm (n = 1). The arteriovenous malformations consisted of Spetzler-Martin grade II (n = 3), grade III (n = 8), and grade IV (n = 4) lesions. Lesion locations included the occipital lobe (n = 15), followed by the tentorial dural (n = 4), temporal-occipital (n = 3), temporal (n = 1), thalamic (n = 1), and quadrigeminal cistern (n = 1) regions. Many patients (75%) experienced transient visual deficits attributable to retraction of the occipital lobe, all of which resolved. As of last follow-up (n = 12), modified Rankin Scale scores had improved for 6 patients and were unchanged for 6 patients compared with the preoperative baseline. CONCLUSIONS: The STIO approach is a safe and effective skull base approach that provides a specialized access corridor for appropriately selected cerebrovascular lesions.

Trends in Matriculation from Neurological Surgery Training Programs into Academic Versus Private Practice.

OBJECTIVE: A career in academic neurosurgery is an arduous endeavor. Specific factors influencing physician practice preferences remain unclear. This study analyzes data from the American Association of Neurological Surgeons membership identifying the impact of several demographic and educational characteristics influencing neurosurgical career choices centered on academia, private practice, or a combination in the United States. METHODS: A list of all current neurosurgeons was obtained from the American Association of Neurological Surgeons membership, and information on physician characteristics was collected via internet searches and institutional databases. The practice type of all neurosurgeons considered in this study were categorized as follows: private practice, academic, or a combination of private practice and academic, termed privademic. These data were subsequently correlated to race, gender, current age, training at a top 40 National Institutes of Health-funded medical school or residency program, and current practice. RESULTS: The median age of private practice and academic neurosurgeons was 58.18 and 53.61 years, respectively (P < 0.001). Age was significantly associated with practicing in an academic setting (odds ratio 0.96), with younger neurosurgeons pursuing careers in academia. Data indicated a positive and statistically significant contribution of female gender (P < 0.001) and training at a top-40 National Institutes of Health-funded institution to practicing in an academic setting (P < 0.01). CONCLUSIONS: Neurosurgery as a field has grown significantly over the past century. The authors recommend that future efforts seek to diversify the neurosurgical workforce by considering practice setting, demographic characteristics, and educational background.

Political Campaign Contributions of Surgeons in the United States Throughout the 2020 Election Cycle.

Importance: Political engagement by the physician workforce is necessary to ensure continued representation of their interests in health care legislation. Limited data are available pertaining to the political involvement of US surgeons. Objective: To analyze the magnitude and distribution of political donations made by all US surgeons throughout the 2020 election cycle. Design, Setting, and Participants: Partisan and geographical differences in surgeon contributions by aggregating data (January 1 through December 31, 2020) from the US Federal Election Commission database were analyzed. Contributions were labeled as Republican, Democrat, or independent depending on the committee they were designated to. Main Outcomes and Measures: Differences in contributions to Republicans, Democrats, and independent candidates for all US surgeons and for subgroups. Results: For the 2020 election year, a total of 53 944 donations were made by surgeons in the United States, amounting to $9 223 350.68. Among all surgical specialties, the top 5 highest number of contributions were made from orthopedic surgeons (n = 15 081), ophthalmic surgeons (n = 14 836), neurological surgeons (n = 7481), urologists (n = 4544), and plastic surgeons (n = 4060). Of these donations, 59.46% (n = 32 107) were made to the Republican party ($5 420 326), 30.83% (n = 16 644) were made to the Democratic party ($1 612 775), and 9.71% (n = 5243) were made to nonpartisan (ie, independent) organizations ($2 190 250). Overall, pediatric surgeons reported the lowest mean contribution amount of $59.43, whereas thoracic surgeons reported the highest mean contribution amount of $225.19. Conclusions and Relevance: Health care legislation has an immense impact on how medicine is practiced and utilized. This analysis reveals a high degree of political activity of surgeons across different specialties and geographic regions.

Evolution of Intracranial-Intracranial Bypass Surgery: A Bibliometric Analysis.

OBJECTIVE: Modern cerebrovascular bypass surgery uses either extracranial-intracranial (EC-IC) or intracranial-intracranial (IC-IC) approaches. Compared with EC-IC bypasses, IC-IC bypasses allow neurosurgeons to safely address tumors, aneurysms, and other lesions using shorter grafts that are well matched to the size of recipient vessels. Fewer than 100 articles have been published on IC-IC bypasses compared with more than 1000 on EC-IC bypasses. This study examined the increase of interest and innovation in IC-IC bypass. METHODS: PubMed and Web of Science were searched using keywords specific to IC-IC bypass, yielding 717 articles supplemented with 36 reports from other databases and gray literature. The articles were reviewed, and 98 articles were selected for further evaluation. Final articles were categorized as innovations or retrospective studies. Publication metrics were passed through an analytic program to assess statistical measures of growth. RESULTS: The number of publications describing innovations (n = 52) and retrospective studies (n = 46) in IC-IC surgical techniques increased exponentially (R2 = 0.983 and R2 = 0.993, respectively), with both interest and research in the field increasing. The rate of publications in each group also increased. In recent years, increasing numbers of global institutions have researched and published on IC-IC bypasses. CONCLUSIONS: As more work is undertaken on IC-IC bypasses, it is critical for knowledge to be shared through research, collaboration, publication, and early teaching within residency training programs. This field has increased exponentially in the past 2 decades and has yet to reach an inflection point, indicating possible additional interest and growth over time.

Optimizing the residency application process: insights from neurological surgery during the pandemic virtual application cycle.

OBJECTIVE: In this article, the authors describe the impact of the COVID-19 virtual match cycle and discuss approaches to optimize future cycles through applicant and neurosurgical education leadership insights. METHODS: Anonymous surveys of neurosurgery program leaders (program directors and program chairs), program administrators (PAs), and 2020-2021 neurosurgery residency match applicants were distributed by the SNS, in conjunction with the Association of Resident Administrators in Neurological Surgery and AANS Young Neurosurgeons Committee. RESULTS: Responses were received from 77 (67.0%) of 115 PAs, 119 (51.7%) of 230 program leaders, and 124 (44.3%) of 280 applicants representing geographically diverse regions. During the virtual application cycle relative to the previous year, programs received more Electronic Residency Application Service applications (mean 314.8 vs 285.3, p < 0.0001) and conducted more applicant interviews (mean 45.2 vs 39.9, p = 0.0003). More than 50% of applicants applied to > 80 programs; 60.3% received ≤ 20 interview invitations, and 9% received > 40 invitations. Overall, 65% of applicants completed ≤ 20 interviews, whereas 34.7% completed > 20 interviews. Program leaders described one 4-week home subinternship (93.3%) and two 4-week external subinternships (68.9%) as optimal neurosurgical exposure; 62.8% of program leaders found the standardized letter of recommendation template to be somewhat (47.5%) or significantly (15.3%) helpful. Applicants, PAs, and program leaders all strongly preferred a hybrid model of in-person and virtual interview options for future application cycles over all in-person or all virtual options. Ninety-three percent of applicants reported matching within their top 10-ranked programs, and 52.9% of programs matched residents within the same decile ranking as in previous years. CONCLUSIONS: Optimizing a national strategy for the neurosurgery application process that prioritizes equity and reduces costs, while ensuring adequate exposure for applicants to gain educational opportunities and evaluate programs, is critical to maintain a successful training system.

Bibliometric Analysis of the Extracranial-Intracranial Bypass Literature.

OBJECTIVE: Extracranial-intracranial (EC-IC) bypass is a procedure in which a blood vessel outside the skull is connected to one inside the skull to improve cerebral blood flow. Certain aneurysms cannot be treated through standard clipping, and EC-IC bypass may be recommended in such cases. A vast body of literature exists on the use of EC-IC bypass as a treatment for cerebrovascular disorders. While beneficial to surgeons, these publications may not reach all the intended audience, which encourages the use of bibliometric analyses. Although a fraction of historically meaningful publications may not have been sufficiently valued through citation count, bibliometric analysis is the gold standard for assessing the impact of a publication. METHODS: Using bibliometric analysis, we queried the Web of Science database to identify the 50 most impactful publications on EC-IC bypass based on citation count. RESULTS: The literature search retrieved 125 publications that met inclusion criteria, from which the top 50 most-cited ones were selected. The mean number of citations for each article was 117.06 (range 35-1437). Case reports and series constituted 15 (30%) of the top 50 publications on EC-IC bypass, followed by 8 (16%) editorials and 7 (14%) randomized controlled trials. A total of 265 authors in 10 countries contributed to the 50 manuscripts, which were published in 15 different journals. CONCLUSIONS: We retrieved the top 50 most-cited articles on EC-IC bypass surgery and identified the landmark publications to provide a foundational understanding of the procedure as a treatment for complex disorders.

Patient satisfaction reviews for 967 spine neurosurgeons on Healthgrades.

OBJECTIVE: Patients are increasingly relying on independent physician rating websites (PRWs) to obtain information about healthcare providers. Healthgrades.com is a widely used PRW that allows patients to rate physicians on various metrics of performance and quality of care. This study categorically investigated the correlations between demographics of spine neurosurgeons and online ratings on Healthgrades to better understand the factors driving patient satisfaction in spine surgery in the United States. METHODS: In August-December 2019, the authors performed a retrospective data analysis using Healthgrades. The American Association of Neurological Surgeons (AANS) membership database was used to identify spine neurosurgeons in the United States and extract biographical and career data. Individuals with an academic practice were further investigated for academic rank, leadership, and fellowship training. Scores from eight patient satisfaction metrics (PSMs) were collected for each surgeon from Healthgrades. RESULTS: A total of 967 spine neurosurgeons were included in the study cohort. Patient satisfaction did not correlate with sex, PhD acquisition, academic status, or academic rank. Among those who were academic surgeons, completion of fellowship training was associated with higher ratings. Geographical location of practice did not influence patient satisfaction. Prolonged wait time was an independent predictor of decreased patient satisfaction and was a key confounding variable underlying trends seen with advanced career duration and age. CONCLUSIONS: Overall, patients rated spine neurosurgeons highly favorably on the Healthgrades website. Due to the emerging role of PRWs in locating and assessing providers, it is important for both patients and clinicians to understand the factors that impact patient experience.

Applying to residency: survey of neurosurgical residency applicants on virtual recruitment during COVID-19.

OBJECTIVE: The COVID-19 pandemic caused a significant disruption to residency recruitment, including a sudden, comprehensive transition to virtual interviews. The authors sought to characterize applicant experiences and perceptions concerning the change in the application, interview, and match process for neurological surgery residency during the 2020-2021 recruitment cycle. METHODS: A national survey of neurosurgical residency applicants from the 2020-2021 application cycle was performed. This survey was developed in cooperation with the Society of Neurological Surgeons (SNS) and the American Association of Neurological Surgeons Young Neurosurgeons Committee (YNC) and sent to all applicants (n = 280) who included academic video submissions to the SNS repository as part of their application package. These 280 applicants accounted for 69.6% of the total 402 neurosurgical applicants this year. RESULTS: Nearly half of the applicants responded to the survey (44.3%, 124 of 280). Applicants favored additional reform of the interview scheduling process, including a centralized scheduling method, a set of standardized release dates for interview invitations, and interview caps for applicants. Less than 8% of students desired a virtual-only platform in the future, though the majority of applicants supported incorporating virtual interviews as part of the process to contain applicant costs and combining them with traditional in-person interview opportunities. Program culture and fit, as well as clinical and research opportunities in subspecialty areas, were the most important factors applicants used to rank programs. However, subjective program "fit" was deemed challenging to assess during virtual-only interviews. CONCLUSIONS: Neurosurgery resident applicants identified standardized interview invitation release dates, centralized interview scheduling methods, caps on the number of interviews available to each candidate, and regulated opportunities for both virtual and in-person recruitment as measures that could significantly improve the applicant experience during and effectiveness of future neurosurgery residency application cycles. Applicants prioritized program culture and "fit" during recruitment, and a majority were open to incorporating virtual elements into future cycles to reduce costs while retaining in-person opportunities to gauge programs and their locations.