Skiing Injuries in the US Pediatric Population: An Analysis of National Injury Trends and Mechanisms Between 2012 and 2022.

Background: While prevention protocols have been implemented, skiing-related musculoskeletal injuries and concussions continue to present to emergency departments in the United States. Previous literature has suggested the pediatric population may constitute up to 40% of skiing-related injuries. Purpose: To assess injury trends and the underlying mechanisms of skiing injuries in pediatric patients seen at emergency departments in the United States. Study Design: Descriptive epidemiology study. Methods: The National Electronic Injury Surveillance System (NEISS) was queried for pediatric (age ≤18 years) skiing injuries between January 1, 2012, and December 31, 2022. Injury mechanism, location, disposition, and diagnosis were recorded, and the statistical sample weight assigned by NEISS by hospital was used to calculate national estimates (NEs). Injury trends were evaluated with linear regression analysis. Results: Overall, 2951 pediatric skiing injuries were included (NE = 123,386). The mean age of the patients was 12.4 ± 3.5 years, with 61.3% of the injuries occurring in male patients. Impact with the ground was the most common injury mechanism (NE = 87,407; 70.8%). Fractures were the most common diagnosis (NE = 38,527, 31.2%), followed by strains/sprains (NE = 22,562, 18.3%), contusions/abrasions (NE = 16,257, 13.2%), and concussions (NE = 12,449, 10.1%). The lower leg was the most common fracture site (NE = 9509, 24.7%), followed by the shoulder (NE = 7131, 18.5%) and lower arm (NE = 5876, 15.3%). Analysis of annual injuries revealed no significant trend between 2012 and 2022 (P = .17), with fluctuations apparent throughout the study period. Significant decreases were seen in strains/sprains (P < .01) and contusions/abrasions (P < .01), but not in concussions (P = .57) or fractures (P = .70). Conclusion: Impacts with the snow/ground made up 70.8% of all injuries. Fractures were the most common injury diagnosis, followed by strains/sprains, with the lower leg being most frequently fractured. While strains/sprains and contusions/abrasions showed a significant decline, there were no significant trends in fractures and concussions between 2012 and 2022.

Effects of hours of sleep on ImPACT concussion testing: comparing baseline with postinjury scores.

OBJECTIVE: The influence of sleep on baseline and postconcussion neurocognitive performance prior to Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) is poorly understood. Since ImPACT is widely used in youth sport to assess neurocognitive performance before and after head injury, it is important to delineate factors that affect testing performance. While some have reported correlations between fewer hours of sleep and lower scores on baseline tests, others have not observed any such associations. Therefore, the authors sought to compare the relationship between sleep and neurocognitive performance on ImPACT at both baseline and postinjury. METHODS: The authors queried a database of 25,815 ImPACT tests taken from 2009 to 2019 by athletes aged 12-22 years. There were 11,564 baseline concussion tests and 7446 postinjury concussion ImPACT tests used in the analysis. Linear regression was used to model the effect of sleep on baseline and postconcussion ImPACT scores adjusting for sex, age, learning disability, attention-deficit/hyperactivity disorder, number of prior concussions, number of games missed, and strenuous exercise before testing. RESULTS: Mean composite scores expectedly were all significantly lower in the post-head injury group compared with the baseline group. In the multivariable analysis, at baseline, hours of sleep significantly affected symptom scores (ß = -1.050, 95% CI -1.187 to -0.9138; p < 0.0001). In the postinjury multivariable analysis, verbal memory (ß = 0.4595, 95% CI 0.2080-0.7110; p = 0.0003), visual memory (ß = 0.3111, 95% CI 0.04463-0.5777; p = 0.0221), impulse control (ß = -0.2321, 95% CI -0.3581 to -0.1062; p = 0.0003), and symptom scores (ß = -0.9168, 95% CI -1.259 to -0.5750; p < 0.0001) were all affected by hours of sleep. CONCLUSIONS: Hours of sleep did not alter neurocognitive metrics at baseline but did have an impact on post-head injury metrics. These findings suggest that individuals may be able to compensate for lack of sleep at baseline but not immediately after concussion. Concussions may reduce cognitive reserve or detract from the brain's resources, making sleep even more important for proper neurocognitive functioning postconcussion. Future work will analyze the effects of sleep on postconcussion test performance.

Return to play after head injury in adolescent sports: evaluating football versus other sports.

OBJECTIVE: Increased adolescent sports participation has raised concerns about higher rates of concussions, a prevalent injury among young athletes with potential long-term effects. Discrepancies in concussion recovery and management protocols across various sports underscore a critical issue in youth athletics. This study aimed to examine the relationship between sport type and the number of games missed following a concussion to inform targeted management strategies. METHODS: Data from 7445 postinjury ImPACT tests for athletes aged 12-22 years, collected from 2009 to 2019, were analyzed across different sports: baseball, basketball, cheerleading, football, ice hockey, lacrosse, soccer, softball, swimming, track and field, volleyball, and wrestling. The number of days and normalized missed games (NMG), a metric accounting for the different number of games in a season for different sports, were used to evaluate the effect of concussions across different sports. ANOVA, t-tests, and linear regression analyses were performed to model the effect of sport type on games missed in a season while controlling for sex, age, concussion history, diagnosed learning disability (DLD), and attention-deficit/hyperactivity disorder (ADHD). RESULTS: Multivariable linear regression analysis demonstrated that football participation significantly increased NMG (ß 1.681, 95% CI 0.807-2.554; p < 0.001) and days missed (ß 1.637, 95% CI 1.044-2.231; p < 0.001) after head injury. Concussion diagnoses were also found to significantly increase NMG (ß 2.344, 95% CI 1.629-3.059; p < 0.001) and days missed (ß 1.560, 95% CI 1.074-2.045; p < 0.001), as well as history of prior concussion (NMG: ß 7.791, 95% CI 7.368-8.215; p < 0.001; days missed: ß 5.232, 95% CI 4.945-5.520; p < 0.001). In contrast, factors such as age, sex, DLD, ADHD, and concussions causing loss of consciousness did not significantly affect NMG or days missed. ANOVA with Tukey Honest Significant Difference indicated that compared with football, ice hockey (mean difference [MD] 5.4 days, p = 0.011) and track and field (MD 4.1 days, p = 0.006) were associated with significantly more days being missed after head injury. Conversely, basketball (MD -3.0, p < 0.001) and volleyball (MD -2.6, p = 0.005) were associated with fewer missed games. CONCLUSIONS: Adolescents playing football missed fewer days and games after concussion than other contact and noncontact sports, including ice hockey and track and field, raising questions about variations in return-to-play protocols and cultural attitudes within sports. Further research is needed to determine the factors affecting games missed across sport types in adolescent athletics and return-to-play protocols.

The effect of age on baseline neurocognitive performance.

OBJECTIVE: Evaluate the independent effect of age on baseline neurocognitive performance. STUDY DESIGN: Baseline ImPACT scores from tests taken by 7454 athletes aged 12-22 from 2009 to 2019 were split into three age cohorts: 12-14 years (3244), 15-17 years (3732), and 18-22 years (477). Linear regression analyses were used to evaluate the effect of age on ImPACT composite scores while controlling for demographic differences, medication-use, and symptom burden. Significance values have been set at p < 0.05. RESULTS: Linear regression analyses demonstrated that increased age does not significantly affect symptom score (ß = 0.06, p = 0.54) but does improve impulse control (ß = -0.45, p < 0.0001), verbal memory (ß = 0.23, p = 0.03), visualmotor (ß = 0.77, p < 0.0001), and reaction time (ß = -0.008, p < 0.0001) scores.  However, age did not have an effect on visual memory scores (ß = -0.25, p = 0.07). CONCLUSIONS: Age was shown to be an independent modifier of impulse control, verbal memory, visual motor, and reaction time scores but not visual memory or symptom scores.  This underscores the previous literature showing developmental differences as age increases among the adolescent athlete population.  This data also indicates the need for repeat neurocognitive baseline testing every other year as baseline scoring is likely to change as athletes become older.

A Novel Port to Facilitate Magnetic Hyperthermia Therapy for Glioma.

High-grade gliomas (HGG) are the most common primary brain malignancy and continue to be associated with a dismal prognosis (median survival rate of 15-18 months) with standard of care therapy. Magnetic hyperthermia therapy (MHT) is an emerging intervention that leverages the ferromagnetic properties of magnetic iron-oxide nanoparticles (MIONPs) to target cancer cells that are otherwise left behind after resection. We report a novel port device to facilitate localization, delivery, and temperature measurement of MIONPs within a target lesion for MHT therapy. We conducted an in-depth literature and intellectual property review to define specifications of the conceived port device. After setting the design parameters, a thorough collaboration with neurological surgeons guided the iterative modeling process. A prototype was developed using Fusion 360 (Autodesk, San Rafael, CA) and printed on a Form 3 printer (Formlabs, Medford, MA) in Durable resin. The prototype was then tested in a phantom skull printed on a Pro-Jet 660Pro 3D printer (3D Systems, Rock Hill, SC) and a brain model based on mechanical and electrochemical properties of native brain tissue. This phantom underwent MHT heating tests using an alternating magnetic field (AMF) sequence based on current MHT workflow. Successful localization, delivery, and temperature measurement were demonstrated. The purpose of this study was twofold: first, to create and validate the procedural framework for a novel device, providing the groundwork for an upcoming comprehensive animal trial and second, to elucidate a cooperative approach between engineers and clinicians that propels advancements in medical innovation.

Clinical Considerations and Outcomes for Spine Surgery Patients with a History of Transplant: A Systematic Scoping Review.

OBJECTIVE: The objective of this study was to investigate the perioperative management and outcomes of patients with a prior history of successful transplantation undergoing spine surgery. METHODS: We searched Medline, Embase, and Cochrane Central Register of Controlled Trials for matching reports in July 2021. We included case reports, cohort studies, and retrospective analyses, including terms for various transplant types and an exhaustive list of key words for various forms of spine surgery. RESULTS: We included 45 studies consisting of 34 case reports (published 1982-2021), 3 cohort analyses (published 2005-2006), and 8 retrospective analyses (published 2006-2020). The total number of patients included in the case reports, cohort studies, and retrospective analysis was 35, 48, and 9695, respectively. The mean 1-year mortality rate from retrospective analyses was 4.6% ± 1.93%, while the prevalence of perioperative complications was 24%. Cohort studies demonstrated an 8.5% ± 12.03% 30-day readmission rate. The most common procedure performed was laminectomy (38.9%) among the case reports. Mortality after spine surgery was noted for 4 of 35 case report patients (11.4%). CONCLUSIONS: This is the first systematic scoping review examining the population of transplant patients with subsequent unrelated spine surgery. There is significant heterogeneity in the outcomes of post-transplant spine surgery patients. Given the inherent complexity of managing this group and elevated mortality and complications compared to the general spine surgery population, further investigation into their clinical care is warranted.

Baseline ImPACT Composite Scores in Student-Athletes With Attention-Deficit/Hyperactivity Disorder.

BACKGROUND: Athletes who are diagnosed with attention-deficit/hyperactivity disorder (ADHD) are at increased risk of concussion compared to other athletes. Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) is a widely used concussion tool, but it relies on pre-injury baseline testing that can be affected by psychiatric conditions. This research aims to determine if there are differences in pre-injury testing composite scores in student-athletes with ADHD compared to those without ADHD diagnosis. METHODS: We obtained 11,563 pre-season ImPACT assessments of 7,454 student-athletes (ages: 12-22) from 2009 to 2019. After exclusions, there were 6,920 control and 276 ADHD subjects. Multivariable linear regression analyses compared the independent effect of ADHD on the six ImPACT composite score metrics with Bonferroni correction for multiple comparisons with a = 0.008. RESULTS: Univariate analyses indicated ADHD is associated with more symptoms as measured by the Post-Concussion Symptom Scale (PCSS) (ß = 2.67, 95% CI: 1.47-3.87, p < .0001) and worse Impulse Control scores (ß = 0.93, 95% CI: 0.33-1.53, p = .002). In multivariate analysis, this association was the same for symptom score (ß = 2.48, 95% CI: 1.22-3.74, p < .0001), but Impulse Control was not significantly different after multiple comparison adjustment (ß = 0.87, 95% CI: 0.22-1.15, p = .009). CONCLUSIONS: The ADHD subjects reported worse symptoms at baseline and had worse Impulse Control in univariate analysis, but not multivariate analysis. These results can further guide clinicians in concussion diagnosis and test interpretations for student-athletes with ADHD, considering the symptom burden at baseline.

Surgical techniques for evacuation of chronic subdural hematoma: a mini-review.

Chronic subdural hematoma is one of the most common neurosurgical pathologies with over 160,000 cases in the United States and Europe each year. The current standard of care involves surgically evacuating the hematoma through a cranial opening, however, varied patient risk profiles, a significant recurrence rate, and increasing financial burden have sparked innovation in the field. This mini-review provides a brief overview of currently used evacuation techniques, including emerging adjuncts such as endoscopic assistance and middle meningeal artery embolization. This review synthesizes the body of available evidence on efficacy and risk profiles for each critical aspect of surgical technique in cSDH evacuation and provides insight into trends in the field and promising new technologies.

Improving Surgeon Well-Being: Ergonomics in Neurosurgery.

BACKGROUND: Musculoskeletal disorders are common among surgeons, and affect most neurosurgeons over the course of their career. Although all subspecialist neurosurgeons may be affected by physical strain, spine surgeons and skull base surgeons have a high propensity for workplace injury as a result of long procedures with repetitive movements in strained physical positions. METHODS: In this review, the prevalence of musculoskeletal disorders in neurosurgery, the state of innovation to improve ergonomics in the operating room for neurosurgeons, and potential limitations in advancing technology with the goal of maximizing neurosurgeon longevity are discussed. RESULTS: Innovations such as robotics, the exoscope, and handheld devices with more degrees of freedom have allowed surgeons to maneuver instruments without exerting excessive effort, all while maintaining neutral body positioning, avoiding joint and muscle strain. CONCLUSIONS: As new technology and innovation in the operating room develop, there has been a larger emphasis placed on maximizing surgeon comfort and neutral positioning, by minimizing force exertion and fatigue.

Bibliometric Analysis of International Medical Graduates and Professorship Promotion in Neurosurgery.

BACKGROUND: International medical graduates (IMGs) comprise ∼25% of physicians in the United States. Differences in promotion rates from assistant to associate to full professorship based on medical school location have been understudied. We aim to stratify odds of professional advancement by 3 categories: IMG with U.S. residency, IMG with international residency, and U.S. medical with U.S. residency training. METHODS: We created and queried a database after exclusions of 1334 neurosurgeons including multiple demographic factors: academic productivity and promotion rates. Stratified logistic regression modeled odds of promotion including the variables: decades out of training, Scopus h-index, gender, and training location. Odds ratios (ORs) and 95% confidence intervals (CIs) for each variable were calculated. RESULTS: Significant predictors of increased associate versus assistant professorship included decades out of training (OR = 2.519 [95% CI: 2.07-3.093], P < 0.0001) and Scopus h-index (OR = 1.085 [95% CI: 1.064-1.108], P < 0.0001) while international medical school with U.S. residency (OR = 0.471 [95% CI: 0.231-0.914], P = 0.0352) was associated with decreased promotion. Significant predictors of associate versus full professorship were decades out of training (OR = 2.781 [95% CI: 2.268-3.444], P < 0.0001) and Scopus h-index (OR = 1.064 [95% CI: 1.049-1.080], P < 0.0001). Attending medical school or residency internationally was not associated with odds of full professorship. CONCLUSIONS: Time out of residency and Scopus h-index were associated with higher academic rank regardless of career level. Attending medical school internationally with U.S. residency was associated with lower odds of associate professorship promotion over 10 years. There was no relationship between IMG and full professorship promotion. IMGs who attended residency internationally did not have lower promotion rates. These findings suggest it may be harder for IMGs to earn promotion from assistant to associate professor in neurosurgery.

Effects of repetitive head trauma on symptomatology of subsequent sport-related concussion.

OBJECTIVE: Adolescent participation in athletics continues to grow, leading to an increasing incidence of sports-related concussion (SRC). The current literature suggests that a greater number of prior concussions positively correlates with a greater number of total symptoms, but the specific concussion-related symptoms are not as well defined. The current study investigated the effects of prior recurrent head injury on the symptom profiles of student-athletes after another suspected concussion. METHODS: A multicenter database consisting of 25,815 Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) results was filtered for student-athletes aged 12-22 years old who competed in 21 different sports. Patients were separated into 2 cohorts: athletes reporting a single prior concussion (SRC1) and athletes reporting 2 or more prior concussions (SRC2+). Comparisons were assessed for differences in 22 symptoms and 4 symptom clusters at baseline, first postinjury test (PI1), and second postinjury test (PI2) by using univariate and multivariate analyses. RESULTS: No differences were seen between SRC1 (n = 2253) and SRC2+ (n = 976) at baseline. At PI1, the SRC2+ group (n = 286) had lower severity of headaches (p = 0.04) but increased nervousness (p = 0.042), irritability (p = 0.028), sadness (p = 0.028), visual problems (p = 0.04), and neuropsychiatric symptoms (p = 0.009) compared with SRC1 (n = 529). Multivariate analysis revealed decreased headache severity with increased prior concussion (ß = -0.27,95% CI -0.45 to -0.09, p = 0.003). Multivariate analysis at PI2 demonstrated the SRC2+ cohort (n = 130) had increased cognitive (ß = 1.22, 95% CI 0.27-2.18, p = 0.012), sleep (ß = 0.63, 95% CI 0.17-1.08, p = 0.007), and neuropsychiatric (ß = 0.67,95% CI 0.14-1.2,0.014) symptoms compared with SRC1 (n = 292). CONCLUSIONS: At longitudinal follow-up, patients with a history of recurrent concussions reported greater symptom burden in cognitive, sleep, and neuropsychiatric symptom clusters but not migraine symptoms. This is an important distinction because migraine symptoms are often more easily distinguishable to patients, parents, and physicians. Careful assessment of specific symptoms should be considered in patients with a history of recurrent head injury prior to return to play.

Evaluation of differences across age groups in the incidence, severity, and recovery of concussion in adolescent student-athletes from 2009 to 2019.

OBJECTIVE: Concussion incidence is known to be highest in children and adolescents; however, there is conflicting evidence about the effect of age on concussion risk and recovery within the adolescent age range. The heterogeneity of results may be partially due to the use of age groupings based on convenience, making comparisons across studies difficult. This study evaluated the independent effect of age on concussion incidence, severity, and recovery in student-athletes aged 12-18 years using cluster analysis to define groupings. METHODS: Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) scores of 11,403 baseline tests and 4922 postinjury tests were used to calculate the incidence rates for adolescent student-athletes grouped into 3 age bands (12-13, 14-15, and 16-18 years of age) on the basis of clustering analysis. The recently created Severity Index was used to compare concussion severity between groups. Follow-up tests for subjects who sustained a concussion were used to evaluate recovery time. The chi-square test and 1-way ANOVA were used to compare differences in demographic characteristics and concussion incidence, severity, and recovery. Multivariable logistic and linear regressions were used to evaluate the independent effects of age on concussion incidence and severity, respectively. Multivariable Cox hazard regression was used to evaluate differences in recovery time. Further analyses were conducted to directly compare findings across studies on the basis of the age groupings used in prior studies. RESULTS: Multivariable regression analyses demonstrated that the 14- to 15-year-old age group had a significantly higher concussion incidence than both the 12- to 13-year-old (14- to 15-year-old group vs 12- to 13-year-old group, OR 1.57, 95% CI 1.16-2.17, p = 0.005) and 16- to 18-year-old (16- to 18-year-old group vs 14- to 15-year-old group, OR 0.79, 95% CI 0.69-0.91, p = 0.0008) age groups. There was no difference in incidence between the 12- to 13-year-old and 16- to 18-year-old groups (16- to 18-year group vs 12- to 13-year group, OR 1.26, 95% CI 0.93-1.72, p = 0.15). There were also no differences in concussion severity or recovery between any groups. CONCLUSIONS: This study found that concussion incidence was higher during mid-adolescence than early and late adolescence, suggesting a U-shaped relationship between age and concussion risk over the course of adolescence. Age had no independent effect on concussion severity or recovery in the 12- to 13-, 14- to 15-, and 16- to 18-year-old groups. Further analysis of the various age groups revealed that results may vary significantly with minor changes to groupings, which may explain the divergent results in the current literature on this topic. Thus, caution should be taken when interpreting the results of this and all similar studies, especially when groupings are based on convenience.

Bibliometric Evaluation of U.S. Neurosurgery Subspecialties and Academic Rank Using RCR Index.

INTRODUCTION: Academic productivity, a key feature of academic neurosurgery, has been linked to academic rank, subspecialty, and institutional rank. Relative Citation Ratio (RCR) has emerged as a new metric of scholarly output that can make field-normalized comparisons between researchers, a feature unavailable in prior metrics such as h-index. Here we evaluate the influence of academic rank and neurosurgical subspecialties on RCR scores. METHODS: We identified 1640 academic neurosurgeons from 115 ACGME-accredited programs in the United States, along with their neurosurgical specialty and demographic information, using publicly available data. Mean RCR (m-RCR) and weighted RCR (w-RCR) for each neurosurgeon were queried from the iCite database, which included publications from 2002-2020. m-RCR and w-RCR scores were compared across subspecialties and academic rank using multivariable regression while controlling for demographic factors. RESULTS: Multivariable analysis indicated that academic neurosurgeons in general neurosurgery (P = 0.039) and pediatric neurosurgery (P = 0.003) had lower m-RCR scores than their peers in other subspecialties. w-RCR did not differ significantly among subspecialties. Higher academic rank was associated with increased m-RCR (P < 0.05) and w-RCR scores (P < 0.0001). CONCLUSIONS: Professors have a higher m-RCR score relative to assistant professors, while general and pediatric neurosurgery were linked to lower m-RCR values. Although neurosurgical subspecialty choice did not influence w-RCR, a higher w-RCR score corresponded to a higher academic rank. Overall, the RCR metric can be utilized for field-normalized comparisons of faculty who differ in academic rank and subspecialty.