Review of global neurosurgery education: Horizon of Neurosurgery in the Developing Countries.

Globally, the discipline of neurosurgery has evolved remarkably fast. Despite being one of the latest medical specialties, which appeared only around hundred years ago, it has witnessed innovations in the aspects of diagnostics methods, macro and micro surgical techniques, and treatment modalities. Unfortunately, this development is not evenly distributed between developed and developing countries. The same is the case with neurosurgical education and training, which developed from only traditional apprentice programs in the past to more structured, competence-based programs with various teaching methods being utilized, in recent times. A similar gap can be observed between developed and developing counties when it comes to neurosurgical education. Fortunately, most of the scholars working in this field do understand the coherent relationship between neurosurgical education and neurosurgical practice. In context to this understanding, a symposium was organized during the World Federation of Neurological Surgeons (WFNS) Special World Congress Beijing 2019. This symposium was the brain child of Prof. Yoko Kato-one of the eminent leaders in neurosurgery and an inspiration for female neurosurgeons. Invited speakers from different continents presented the stages of development of neurosurgical education in their respective countries. This paper summarizes the outcome of these presentations, with particular emphasis on and the challenges faced by developing countries in terms of neurosurgical education and strategies to cope with these challenges.

Correction to: Review of global neurosurgery education: Horizon of Neurosurgery in the Developing Countries.

[This corrects the article DOI: 10.1186/s41016-020-00194-1.].

Epidemiological characteristics of surgically treated civilian traumatic brachial plexus injuries in Serbia.

BACKGROUND: Traumatic brachial plexus injuries are generally severe, and in many cases associated with surrounding tissue injuries, which makes them hard to diagnose at the right time. This paper presents etiological and epidemiological characteristics of surgically treated civilian traumatic brachial plexus injuries. METHODS: This retrospective study included 68 patients, operated due to the traumatic brachial plexus injuries at Clinic for Neurosurgery, Clinical Center of Serbia, during the 11-year period. RESULTS: The vast majority of injured patients were men in full working maturity. In our study, there were seven different etiological factors. The road traffic accidents were the most common-41 (60.3%), while the motorcycle accidents were the most dominant subtype (53.7%) of all road traffic accidents, and also representing 32.4% of all causes of trauma. Supraclavicular elements of the brachial plexus were injured in more than 80% of patients. A total of 49 (72.1%) patients from our study had one or more associated injuries. The most common associated injuries were bone fractures, brain contusions, and vascular injuries. CONCLUSION: Although rare, non-war-related severe brachial plexus injuries represent a group of patients carrying high risk of insufficient functional recovery regardless of treatment modality, or surgical technique. Epidemiological and etiological data are therefore very important to identify the groups in risk and to induce preventive actions aimed at these patients.

[Current trends in surgical treatment of radial nerve injuries associated with injuries of the humerus].

Radial nerve is the most common injured peripheral nerve after bone and wrist injuries in human body. Radial nerve can be injured by force causing fracture of the humeral shaft, due to compound fracture of the bone or by direct injury with small fragments of the bone. This happen in of cases and in remaining caseswas caused by manipulation during the treatment of the fracture of the humeral shaft. Because of the possibility of spontaneous recovery, indication and timing of surgical treatment of the radial nerve still remain controversial. There is contradictory approach in the treatment of the injured radial nerve. In a period betwen 1979 and 2005 year we have operated 193 patients with injury of radial nerve. Among them, 97 (50.2%) have had combined injury of the humeral shaft or proximal part of radius. Rest of injuries of the radial nerve were associated with manipulation during treatment. Surgical treatment has been performed in a period between three and four months after neurological deficit. Analysing our result regarding recovery of the motor function we have used combination of gradation including British Medical Council Score and modified Highet Scale to obtain satisfactory analysis of useful functional recovery of motor function after surgical procedure. We have classified results as bad M O-2 for all muscles innervated by the radial nerve; satisfactory M3, for extensors of the wrist and fingers and M O-2 for abductor of the thumb, good M 4-5 extensors of the wrist and fingers and M3 for abductor of the thumb, and excellent M 4-5 for all muscles.

[Carpal tunnel syndrome--surgical and anesthesiology considerations].

Carpal tunnel syndrome presents the most common peripheral nerve entrapment, and section of carpal transverse ligament is the most common procedure in peripheral nerve surgery. Favourable outcomes depend on several factors including correct diagnosis, careful patient selection, precise operative technique and appropriate postoperative care. The goal of this paper is to establish the most common causes of failed surgery analysing primary and secondary outcomes, and to give the possibility for better results in the future. Analysis was based on 250 operated patients. Primary outcome and secondary outcome 3 months after surgery was estimated. Total rate of complications was 8% with persistent complaints in 7 (35%) patients and recurrent symptoms in 13 (65%) patients.

[The position of anterior cuciate ligament in frontal and sagittal plane].

INTRODUCTION: Position of the anterior cruciate ligament (ACL) represents one of the anatomical factors which can lead to the rupture of the ligament. AIM: The aim of this study was to overview and compare gender and age differences of the position of the ACL and its relation with the medial aspect of the lateral femoral condyle. METHOD: The measurements were performed on the fifty cadaver knees (32 male and 18 female) aged between 15 - 53 years with intact ACL. We were measuring the angle of the ACL in sagittal and frontal plane and the angle of the medial aspect of the lateral condyle in frontal and horizontal plane. RESULTS: Measurements of the ACL in sagittal plane and measurements of the angle of the medial aspect of the lateral femoral condyle in horizontal plane showed statistically significant variations with the age (p < 0.05 and p < 0.01, respectively). The angle of the medial aspect of the lateral femoral condyle in frontal plane was statistically significant higher than the same measured angle in the horizontal plane ( p < 0.01). CONCLUSION: ACL fomis narrower angle with medial aspect of the lateral femoral condyle in extension of lower leg than in flexion as a result of smaller angle of the medial aspect of the lateral femoral condyle in frontal compared to horizontal plane.

[Morphologic analysis of the coexisting anomalies of the arteries of the cerebral base and aneurysms: clinical study].

During operations of the aneurysms showing anatomical details is the means that leads to the aim, and it is not only a purpose in itself. Data on details that the surgeons come across during their work and which sometimes represent difficulties during interpretations of angiographic findings and planning operations, as well as the intraoperative orientations and identifications of the elements . Frequency of occurrence of such anatomical details and anomalies may be completely different from the one that autopsy series show. Knowledge of this makes the work of surgeons easier and gives a necessary feeling of confidence during operations. Thus, we decided to conduct a clinical, morphological study based on angiographic and surgical analyses of the explored segments of the Wilson circle. The study included 344 patients from the Institute for Neurosurgery, during the period of 2 years; the patients had complete angiographic diagnosing and operative exploration. Our findings confirm differences in localization of aneurysms according to sex. Aneurysms on the front communicant complex are to a great extent associated with anomalies of the front part of the Wilson circle.

[Screening of risk groups for discovering intracranial aneurysms before rupture].

In development of intracranial aneurysms contribute genetic factors together with smoking, hypertension, diabetes mellitus. Epidemiology studies suggest that as many as 5% of people harbour a cerebral aneurysm by age 75. Rupture of cerebral aneurysm is the most frequent cause of spontaneous subarachnoid haemorrhage (up to 80%.) Annual incidence of SAH is 10-14/100 000, but only 15-20% of aneurysms will rupture, and that will happen probably between 40-60 years. The morbidity and mortality of aneurismal subarachnoid (SAH) continues to be high. It is not possible to predict who has aneurysm and is it going to bleed or not, but it is possible to reveal high risk groups (polycystic kidney disease, Ehlers-Danlos sy, Marphan sy, family history of cerebral aneurysms, suspect de novo aneurysm formation in patients with prior history of cerebral aneurysm). Reviewing data from literature and reporting cases from each group with high risk, that have been screened and aneurysms discovered, authors wish to focus interest on this matter and propose screening program for these groups of patients. The mortality and morbidity in cases treated before rupture is significantly lower than after SAH, so screening programs could save many lives. According to our preliminara data, mostly based on control angiographies after 8-10 zears in patients previouslz operated for intracranial aneurysmas, from 15 angipgraphies 4 revealed new aneurysms (26% in 10 years period) with total number of 6 de novo formed aneurysms, which is not valid due to small number of patients but strongly suggests the importancy of screening program for risk groups.

[Space reconstruction of the aneurysms of the vertebrobasilary confluence based on conventional angiography--our experience].

Besides current development of the new diagnostic procedures conventional angiography still represents the golden standard in the diagnosing of intracranial aneurysms. Since it gives a two-dimensional image if the presentation of the third dimension is wanted it is necessary to apply appropriate algorithm structures and computers. In this study we show our experience in the application of space reconstruction of blood vessels and aneurysms of the vertebrobasilary confluence in 6 patients operated at the Institute for Neurosurgery, Clinical Center of Serbia. Intraoperative finding in all patients matched the finding that we got by space reconstruction of the blood vessels, which was possible to observe from different angles. Postoperative course in all patients was satisfying. Upon discharge the patients were without rough lateralization of the pyramidal system. Our initial results and their practical agreement with the interoperative finding give us right to recommend this method as the standard for the preoperative diagnostic protocol.

[Neurovascular compression (conflict)]].

Since Dandy first reported vascular compression of the trigeminal nerve, the concept of neurovascular compression syndrome for trigeminal neuralgia and hemifacial spasm (HFS) has been accepted, and neurovascular decompression has been performed for this condition. The further investigations indicated that some other clinical syndromes such as glossopharyngeal neuralgia, disabling positional vertigo, tinnitus, geniculate neuarlgia, spasmodic torticolis, essential hypertension, cyclic oculomotor spasm with paresis and superior oblique myokymia also may be initiated by vascular compression of the glossopharyngeal, cochleovestibular, intermediate, accessory, oculomotor and trochlear nerves or the ventrolateral medulla oblongata. In this study several hypotheses regarding the development of cranial nerves vascular compression syndromes are presented. It is alsoemphasized the value of high-resolution magnetic resonance tomographic angiography for visualization of vascular compression. The most frequent clinical syndromes caused by vascular compressionof the cranial nerves are discussed regarding the pathogenesis, symptomes and therapy. We present our series of 124 patients with preoperative evidently positive finding of vascular compression to the trigeminal nerve (MRI). Microvascular decompression (MVD) was performed in all of them. Initial postoperative result was excellent in 110/124 (89%) patients,while in 11/124 (9%) patients the pain relief was satisfactory. In the remaining three patients MVD failed. Recurrence of pain after two years reached 19%. Complications were related to diplopia associated with transient fourth nerve dysfunction in 5 (4%) patients, facial motor dysfunction in 4 (3%) patients, transient facial hypesthesia in 27 (22%) patients and partially hearing loss in 4 (3%) patients. Cerebellar hemorrhagic infarction occurred in 1 (0.8%) patient and cerebrospinal fluid leaks appeared in two (1.6%) cases. There was no lethal outcome.

[Reconstruction of the alae nasi by folded nasolabial flap].

Reconstruction of the nose is very old surgical procedure and, in fact, represents the beginnings of plastic surgery. In reconstruction, an effort has to be made in order to achieve a normal look. A surgeon must choose carefully the method of reconstruction, taking into consideration the skin color, texture and nasal topography. Full-thickness nasal defects in alar region are very difficult for reconstruction due to anatomic characteristics and structures, which are very important for normal breathing and cosmetic result. Our study analyzed 16 patients with full-thickness defect of alae nasi. Folded nasolabial flaps were used for reconstruction of these defects. Good results were achieved in all cases. The flap was vital. No flap necrosis was reported in any of these patients. The lining of the nose was good. Postoperatively, the alar edge was thickened, but it became thinned after six months. The incision in donor's region was well placed in the natural line of nasolabial fold. It was concluded that folded nasolabial flap was extremely good one-step procedure for reconstruction of full-thickness defects of alar region.

[The excision width in surgical treatment of basal cell carcinoma].

Basal cell carcinoma originates from pluripotent cells of basal layer of epiderm, external covering of hair follicles, sebaceous glands or other skin adnexa. It is characterized by local infiltrating and sometimes destructive growth. There are several types of basal cell carcinomas that may be manifested in over 12 clinical forms. Surgical treatment depends to a large extent on the histological type, localization and its clinical manifestation. The analysis included 250 patients of both gender and different age, operated for basal cell carcinoma. Clinical characteristics of basal cell carcinoma and the width of the excision were described. It was concluded that the width of the excision of basal cell cancer was in relation to histological type.

The use of thoracodorsal nerve transfer in restoration of irreparable C5 and C6 spinal nerve lesions.

There are only a few reports on the use of thoracodorsal nerve (TDN) transfer to the musculocutaneous or axillary nerves in cases of directly irreparable brachial plexus injuries. In this study, we analysed outcome and time-course of recovery in correlation with recipient nerves and type of nerve transfer (isolated or in combination with other collateral branches) for 27 patients with transfer to the musculocutaneous or axillary nerves. Using this nerve as donor, we obtained useful functional recovery in all 12 cases for the musculocutaneous nerve, and in 14 (93.3%) of 15 nerve transfers for the axillary nerve. Although, we found no significant statistical difference between analysed patients according to the percentage of recoveries and mean values, we established a better quality and shorter time of recovery for the musculocutaneous nerve. According to obtained results, we consider that transfer may be a valuable method in reconstruction after directly irreparable C5 and C6 spinal nerve lesions.

[Indications for surgical treatment of pain and types of operations]. / Indikacije za hirursko lecenje bola i vrste operacija.

During the period from 1978 to 2003 in Institut for neurosurgery CCS and Neurosurgical hospital of MA in Belgrade, 3057 patients with pain syndroms in different localisations were operated. Before operation all conservative methods were exhausted. We made 248 microvacular decompressions in fossa cranii posterior, 1600 radiophrequent lessions of ggl. Gasseri and 64 avulsions of distal trigeminal branches in patients with trigeminal and glossopharingeal neuralgia, 128 chordotomies in patients with neurogenic and cancer pain, 62 DREZ operations in patients with paraplegia, cancer pain and postherpetic intercostal neuralgia. More than 900 patients have been operated because of neuropathic pain and trauma of peripheral nerves, and 48 patients were operated due to Phantomzs pain. We compared results of two alternative methods in treatment of trigeminal neuralgia (radiophrequent lesion of ggl. Gasseri and microvascular decompression in posterior fossa).

[Avulsion of the peripheral nerve of the trigeminal nerve]. / Avulzije zavrsnih grana trigeminalnog nerva.

There are variety of surgical methods in treating trigeminal neuralgia. They can all be devided in two large groups: less invasive procedures and decopmressive procedures in the region of pontocerebelar angle. Peripheral neurectomy, exeresis or avulsion of peripheral branches of trigeminal nerv are methods for elderly patients with serious cardiopulmonal disturbances. We performed avulsion of peripheral branches at 58 patients, all older than 60 years. In 32 patients we did avulsion of only one of three branches of trigeminal nerv, while in 26 patients the combined avulsion of two branches was performed. There were no postoperative complications.

[Cordotomy in the treatment of pain conditions]. / Hordotomija u lecenju bolnih stanja.

During the time interval from January 1978 to January 2003, total of 128 chordotomy procedures have been done due to cancer's pain at the Institute of neurosurgery in Clinical Centre of Serbia. That pain has been mostly of uncontrolled intensity and it was resistant on applieed conservative treatment. Bilateral chordotomy has been performed in 6 patients only in exceptional cases when fixed paraplegia has proved; unilateral chordotomy has been performed in 122 cases. Bilateral chordotomy is much more dangerous than unilateral one because of greater posibility of appearance of motor deficits, sphincteral disturbances or subsequent formed pain. This procedure has several negative aspects. Firstly, it is an opened surgical intervention in general anesthesia and therefore, there is no communication with patient. We had a habit to perform DREZ surgery rather than chordotomy when ever it has been indicated. In 80.1% of all cases, the successfulness of surgery has been marked as excellent, in 15.2% of all cases, it has been marked as good, and in 4.7% of all cases, bad outcome has been detected. The rate of complication was 4.4%.

[Phantom pain and posttraumatic pain conditions]. / Fantomski bol i posttraumatska bolna stanja.

After limb or body part amputation, three different types of perceptual sensitive phenomena can be recognized. They can be all named posttraumatic neuropathies: painless sensations in phantom limb, painful phantom limb and painful posttraumatic stump. Painless sensations in phantom limb can be seen in 90% of cases in resected body parts as soon as first postoperative day, less often during the first week, and its clinical characteristics are usually stabilized during the first year. Painful posttraumatic stump appears because of pain neuroma existing, that forms at the proximal end of amputational stump as a consequence of physiological nerve regeneration attempt. Frequency of pain significantly varies considering authors from 5-90%, depending on definition of this phenomena and criteria used. It is considered that 5-10% mast be under permanent medicament treatment. Phantom pain appears more often in elderly and people with specific affective personality construction. It can be permanent, burning, nettling, tearing (25%), or intermittent, lancerating, in the shape of electrical discharging (32%), but it can also have bizarre attributes. Phantom pain appearance usually announces its duration in the longer period. After two years it is present at 59% of patients, with decreasing intensity, and only 5-10% suffer severe pain. In our Institute in the period from 1980-2003, 48 patients have been treated, 36 patients with medicamentous treatment, local blockades and chronic stimulations, and 12 patients, who did not react at conservative treatment were operated. In operated group in 10 patients pain disappeared, one patient it was with decreasing intensity, and one patient was without change.

[Significance of sensory evoked potentials in determination of the level of brachial plexus injuries]. / Znacaj senzorno evociranih potencijala u visinskoj leziji brahijalnog pleksusa.

The aim of this work is to show the highlights of electrophysiological diagnostics, i.e. its potentials in level diagnostics of traumatic disfunction of brachial plexus (BP). In that manner we have analyzed the results of electrophysiological research, made on 53 patients with different levels and grades of traumatic lesion of brachial plexus. We have also analyzed the authors' opinions and points of view who have contributed in solving these problems. Brachial plexus is a complex, vulnerable nerve structure that is often, in life, exposed to direct or indirect influence of mechanical force. Preserved integrity of bone structures of a shoulder protects BP from longitudinal forces, which are the most common causes of injury of this structure. Traction mechanism of the injury is always up to date in the cases of fractures and dislocation of the skeleton in this region. In the early childhood, mechanical injuries of brachial plexus are caused by distocia in the second delivery period, while in adulthood most common injuries are caused by sudden and intensive forces, which cause disfunction of plexus by traction mechanism (dislocation of a shoulder and clavicular fracture) and by direct action (stabing and piercing injuries). Slowly progressive, expansive, degenerative and inflammatory processes of neighbouring organs are causing the disfunction of the plexus as well. Traction actions are aimed mostly at radiculars as a vulnerable structure that is placed between relatively mobile shoulder joint and rigid cervical part of vertebral column. Complex anatomical structure and mutual overlapping of radicular motor and sensitive innervation of muscles and dermatoms, make the diagnostics of disfunction of this periphery nerve structure very difficult and complicated. Disfunction of neighboring bone, vascular and muscle elements as well as the nearness of vital organs, which complicates even more the diagnostics. Taking into account the general analysis of all electrophysiological results of the research on 53 patients with an PB injury, we have concluded that none of the functional methods is not sovereign, i.e. the contribution of this research is complementary also with roentgenological results. Clinical data are unavoidable, but they are not enough without good argumentation, especially for the level of lesion, pre- or postganglionary. Electromiography gives reliable results for the phase and the grade of denervation of particular muscle groups, and that way it is possible to conclude, indirectly, which part of the plexus is in disfunction. Special attention should be paid to EMG of paraspinal muscles, where the signs of denervation are aleays indicating intradural lesion of the radicular. In the examined group, 52% of the patients with radicular disfunction had the signs of denervation in paraspinal muscles. Examination of the sensitive action potentials is another method by which we can see the disfunction level of the plexus in an anesthetical region. In a group with preganglionary root disfunction, 48% of the patients had preserved sNAP response. In a group with postganglionary disfunction, 36% of the patients had no sNAP response. Somatosemsory evoked potentials are addition to EMG and ENG research and they are efficient in the primary phase, when electromyographic and electroneurographic examinations are not offering relevant data. Checking of the early diagnostics of the pre- and postganglionary lesions with somatosensory evoked potentials wasn't possible in this group because the first examinations of these patients in our laboratory were mostly made couple of months after the injury. Disfunction of the ratio amplitudes N9 and P/N13 in the group with preganglionary lesion was found in 31%, with postganglionary in 42.2% and with both in 10% of the patients.

[Nerve transfer in brachial plexus injuries--comparative analysis of surgical procedures]. / Nervni transfer kod povreda brahijalnog pleksusa--komparativna analiza hirurskih procedura.

Nerve transfer is the only possibility for nerve repair in cases of the brachial plexus traction injuries with spinal roots avulsion. From 1980. until 2000. in Institute of Neurosurgery, Clinical Center of Serbia, nerve transfer has been performed in 127(79%) of 159 patients with traction injuries of brachial plexus, i.e., 204 reinnervation procedures has been performed using different donor nerves. We achieved good or satisfactory arm abduction and full range or satisfactory elbow flexion through reinnervation of the axillary and musculocutaneous nerve using different donor nerves in 143 of 204 reinnervations, which presents general rate of useful functional recovery in 70.1% of cases. Mean values of the rate of useful functional recovery in individual modalities of nerve transfer in our series are 50.1% for intercostal and/or spinal accessory nerve transfer, 64.5% for plexo-plexal nerve transfer, 81.7% for regional nerve transfer, and 87.1% for combine nerve transfer.

[Transplantation in peripheral nerve injuries]. / Transplantacija kod povreda perifernih nerava.

Autologous nerve grafting is the most commocommnlynly used operative technique in delayed primary, or secondary nerve repair after the peripheral nerve injuries. The aim of this procedure is to overcome nerve gaps that results from the injury itself, fibrous and elastic retraction forces, resection of the damaged parts of the nerve, position of the articulations and mobilisation of the nerve. In this study we analyse the results of operated patients with transections and lacerations of the peripheral nerves from 1979 to 2000 year. Gunshot injuries have not been analyzed in this study. The majority of the injuries were in the upper extremity (more than 87% of cases). Donor for nerve transplantation had usually been sural nerve, and only occasionally medial cutaneous nerve of the forearm was used. In about 93% of cases we used interfascicular nerve grafting, and cable nerve grafting was performed in the rest of them. Most of the grafts were 1 do 5 cm long (70% of cases). Functional recovery was achieved in more than 86% of cases, which is similar to the results of the other authors. Follow up period was minimum 2 years. We analyzed the influence of different factors on nerve recovery after the operation: patient's age, location and the extent (total or partial) of nerve injury, the length of the nerve graft, type of the nerve, timing of surgery, presence of multiple nerve injuries and associated osseal and soft tissue injuries of the upper and lower extremities.