Efficacy and utility of antifibrinolytics in pediatric spine surgery: a systematic review and network meta-analysis.

Antifibrinolytics have gained increasing attention in minimizing blood loss and mitigating the risks associated with massive transfusions, including infection and coagulopathy in pediatric patients undergoing spine surgery. Nevertheless, the selection of optimal agent is still a matter of debate. We aim to review the utility of these agents and compare the efficacy of antifibrinolytics in pediatric and adolescent spine surgeries. A comprehensive search was performed in Scopus, Web of Science, and MEDLINE databases for relevant works. Studies providing quantitative data on predefined outcomes were included. Primary outcome was perioperative bleeding between the groups. Secondary outcomes included transfusion volume, rate of complications, and operation time. Twenty-eight studies were included in the meta-analysis incorporating 2553 patients. The use of Tranexamic acid (RoM: 0.71, 95%CI: [0.62-0.81], p < 0.001, I2 = 88%), Aprotinin (RoM: 0.54, 95%CI: [0.46-0.64], p < 0.001, I2 = 0%), and Epsilon-aminocaproic acid (RoM: 0.71, 95%CI: [0.62-0.81], p < 0.001, I2 = 60%) led to a 29%, 46%, and 29% reduction in perioperative blood loss, respectively. Network meta-analysis revealed higher probability of efficacy with Tranexamic acid compared to Epsilon-aminocaproic acid (P score: 0.924 vs. 0.571). The rate of complications was not statistically different between each two antifibrinolytic agent or antifibrinolytics compared to placebo or standard of care. Our network meta-analysis suggests a superior efficacy of all antifibrinolytics compared to standard of care/placebo in reducing blood loss and transfusion rate. Further adequately-powered randomized clinical trials are recommended to reach definite conclusion on comparative performance of these agents and to also provide robust objective assessments and standardized outcome data and safety profile on antifibrinolytics in pediatric and adolescent pediatric surgeries.

Surgeon variation: a south african spinal pathology treatment survey.

PURPOSE: To investigate variation in treatment decisions among spine surgeons in South Africa and the association between surgeon characteristics and the treatment they select. METHODS: We surveyed 79 South African spine surgeons. We presented four vignettes (cervical spine distractive flexion injury, lumbar disc herniation, degenerative spondylolisthesis with stenosis, and insufficiency fracture) for them to assess and select treatments. We calculated the index of qualitative variation (IQV) to determine the degree of variability within each vignette. We used Fisher's exact, and Kruskal-Wallis tests to assess the relationships between surgeons' characteristics and their responses per vignette. We compared their responses to the recommendations of a panel of spine specialists. RESULTS: IQVs showed moderate to high variability for cervical spine distractive flexion injury and insufficiency fracture and slightly lower levels of variability for lumbar disc herniation and degenerative spondylolisthesis with stenosis. This confirms the heterogeneity in South African spine surgeons' management of spinal pathologies. The surgeon characteristics associated with their treatment selection that were important were caseload, experience and training, and external funding. Also, 19% of the surgeons selected a treatment option that the Panel did not support. CONCLUSION: The findings make a case for evaluating patient outcomes and costs to identify value-based care. Such research would help countries that are seeking to contract with providers on value. Greater uniformity in treatment and easily accessible outcomes reporting would provide guidance for patients. Further investment in training and participation in fellowship programs may be necessary, along with greater dissemination of information from the literature.

The Epidemiology of Brain and Spinal Cord Tumors.

CNS tumors are a diverse group of neoplasms that emerge from a variety of different CNS cell types. These tumors may be benign, malignant, or borderline in nature. The majority of high grade glial tumors are fatal, with the exception of pilocytic astrocytoma. Primary malignant CNS tumors occur at a global annual rate of 2.1 to 5.8 per 100,000 persons. Males are more likely to develop malignant brain tumors than females, whereas benign meningiomas are more common in adult females. Additionally, gender inequalities in non-malignant tumors peak between the ages of 25 and 29 years. Only a small number of genetic variants have been associated with survival and prognosis. Notably, central nervous system (CNS) tumors exhibit significant age, gender, and race variation. Race is another factor that affects the incidence of brain and spinal cord tumors. Different races exhibit variation in terms of the prevalence of brain and CNS malignancies. This chapter discusses ongoing research on brain and spinal cord tumor epidemiology, as well as the associated risks and accompanied disorders.

Learning curves in robotic neurosurgery: a systematic review.

The transition to performing procedures robotically generally entails a period of adjustment known as a learning curve as the surgeon develops a familiarity with the technology. However, no study has comprehensively examined robotic learning curves across the field of neurosurgery. We conducted a systematic review to characterize the scope of literature on robotic learning curves in neurosurgery, assess operative parameters that may involve a learning curve, and delineate areas for future investigation. PubMed, Embase, and Scopus were searched. Following deduplication, articles were screened by title and abstract for relevance. Remaining articles were screened via full text for final inclusion. Bibliographic and learning curve data were extracted. Of 746 resultant articles, 32 articles describing 3074 patients were included, of which 23 (71.9%) examined spine, 4 (12.5%) pediatric, 4 (12.5%) functional, and 1 (3.1%) general neurosurgery. The parameters assessed for learning curves were heterogeneous. In total, 8 (57.1%) of 14 studies found reduced operative time with increased cases, while the remainder demonstrated no learning curve. Six (60.0%) of 10 studies reported reduced operative time per component with increased cases, while the remainder indicated no learning curve. Radiation time, radiation time per component, robot time, registration time, setup time, and radiation dose were assessed by ≤ 4 studies each, with 0-66.7% of studies demonstrated a learning curve. Four (44.4%) of 9 studies on accuracy showed improvement over time, while the others indicated no improvement over time. The number of cases required to reverse the learning curve ranged from 3 to 75. Learning curves are common in robotic neurosurgery. However, existing studies demonstrate high heterogeneity in assessed parameters and the number of cases that comprise the learning curve. Future studies should seek to develop strategies to reduce the number of cases required to reach the learning curve.

Incidence of venous thromboembolism in hospitalized pediatric neurosurgical patients: a retrospective 25-year institutional experience.

PURPOSE: Venous thromboembolism (VTE) refers to both deep venous thrombosis (DVT) and pulmonary embolism (PE). The risk of VTE in adult neurosurgical patients is thoroughly studied. However, the incidence and risk of VTE in a comprehensive pediatric neurosurgical population is not well-defined. The available pediatric data consists of reviews of specific high-risk groups, such as trauma, critical care, or cancer patients. This may not be reflective of the entire spectrum of a high-volume pediatric neurosurgery practice. This study was undertaken to analyze the incidence and risk factors of VTE in all hospitalizations evaluated by a pediatric neurosurgery service over a 25-year period. METHODS: A retrospective review of electronic medical records was performed for 9149 hospitalizations in 6374 unique patients evaluated by the pediatric neurosurgery service at Riley Hospital for Children (Indianapolis, IN, USA) from 1990-2014. During this time period, there was no standardized VTE prevention protocol. The study group included all patients less than 18 years of age. Patients with a known pre-existing VTE or pregnancy were excluded. RESULTS: VTE was diagnosed in 20 of the 9149 (0.22%) hospitalizations, in 18 unique patients. All DVTs were diagnosed via Doppler ultrasound and/or computed tomography. Anatomic clot locations included 9 in the upper extremity (0.098% of hospitalizations), 8 in the lower extremity (0.087%), and 4 (0.044%) pulmonary emboli. Ten of the 20 occurred in hospitalizations where the patient underwent surgery, although the need for surgery was not a statistically significant risk factor. Sixteen of the 20 (80%) occurred in patients with at least one form of central venous line (p < 0.00001). There was one VTE-related death (0.01%). CONCLUSIONS: In all pediatric neurosurgical patients, a VTE was found in 0.22% of hospitalizations over a 25-year span. Statistically significant risk factors for VTE included central venous line placement, paralysis, malignancy, intubation greater than 48 h, and hypercoagulable state.

Anterior communicating artery aneurysm rupture and functional outcome in short-term: clipping versus coiling.

Our research aims to assess the change in the grade of responsiveness using the Hunt and Hess score as well as the modified ranking scale in patients suffering from anterior communicating artery rupture. We retrospectively analyzed data from 11-patients who suffered from an anterior communicating artery aneurysm rupture that caused a subarachnoid hemorrhage. Severity was assessed using the Hunt and Hess scale grade and modified ranking scale. Anterior communicating artery rupture caused a subarachnoid hemorrhage in 40.81% of all aneurysm ruptures that took place at the Circle of Willis. Unfortunately, 4-patients deceased (3.4%) at a median age of 52-years (range 34-75-years), three of which deceased after coiling and one after clipping. In 71-patients (61.2%) endovascular coiling was performed - 33-males and 38-females - and in the remaining 45-cases, (38.8%) clipping was indicated - 24-males and 21-females. Overall, the pre-interventional median Hunt and Hess scale was 2, which remained after the intervention. When relating the outcome score to the intervention performed, we found that the Hunt and Hess scale score was 3 before coiling and 2 before clipping, whereas afterward, there was a slight increase to 2 and 2, respectively. The modified ranking scale was 2 after clipping, respectively, coiling (P = 0.218). No significant differences were observed between the different groups. Our results show that clipping is as effective as coiling in terms of the Hunt and Hess scale and the rate of mortality in the short-term.

A prospective randomized clinical trial to evaluate the impact of intraoperative ventilation with high oxygen content on the extent of postoperative pneumocephalus in patients undergoing craniotomies.

Purpose of the article: To determine whether intraoperative ventilation with pure oxygen during the last stage of surgery reduces the occurrence and volume of postoperative pneumocephalus when compared to conventional air/oxygen mixture in patients undergoing craniotomy. MATERIAL AND METHODS: prospective randomized single-blinded study to compare the rate of occurrence and volume of postoperative pneumocephalus in patients undergoing craniotomy receiving intraoperative ventilation with pure oxygen (Group B) versus a conventional air/oxygen 1:1 mixture (Group A) during the last stage of surgery. This trial was registered in ClinicalTrials.gov #NCT02722928, protocol number 2015H0032. RESULTS: One hundred patients were randomized into group 'A' and group 'B'. Seventy patients were included in the final analysis with 39 patients allocated in group 'A' and 31 patients in group 'B'. Median and IQR were used for postoperative penumocephalus volume. Group A: 9.65 [3.61-23.20]; Group B: 7.06 [2.70-20.1]. Our study showed no prophylactic effect on postoperative pneumocephalus volume when using mechanical ventilation with higher oxygen concentrations than the standard FiO2 during the last stage of surgery in patients undergoing craniotomy (p = .47). No statistical difference was found in SICU LOS between groups (median 1,380 min [group A] versus 1,524 min [group B]; p = .18). CONCLUSION: The use of intraoperative mechanical ventilation with pure oxygen was not associated with a prophylactic effect on the occurrence and extent of postoperative pneumocephalus in our patient setting. Published literature describing the extent of postoperative pneumocephalus is limited or highly variable among institutions.

Bridging the gap: creating a self-sustaining neurosurgical residency program in Haiti.

Given Haiti's longstanding socioeconomic burden and recent environmental and epidemiological catastrophes, the capacity for neurosurgery within Haiti has been limited, and outcomes for patients with neurosurgical conditions have remained poor. With few formally trained neurosurgeons (4) in a country of 10.5 million inhabitants, there is a significant need for the development of formal structured neurosurgical training. To mitigate the lack of neurosurgical care within Haiti, the authors established the first neurosurgical residency program within the country by creating an integrated model that uniquely fortifies existing Haitian neurosurgery with government sponsorship (Haitian Ministry of Health and National Medical School) and continual foreign support. By incorporating web-based learning modules, online assessments, teleconferences, and visiting professorships, the residency aims to train neurosurgeons over the course of 3-5 years to meet the healthcare needs of the nation. Although in its infancy, this model aims to facilitate neurosurgical capacity building by ultimately creating a self-sustaining residency program.

Neurosurgical digital teaching in low-middle income countries: beyond the frontiers of traditional education.

OBJECTIVE: Neurosurgical training is usually based on traditional sources of education, such as papers, books, direct surgical experience, and cadaveric hands-on courses. In low-middle income countries, standard education programs are often unavailable, mainly owing to the lack of human and economic resources. Introducing digital platforms in these settings could be an alternative solution for bridging the gap between Western and poor countries in neurosurgical knowledge. METHODS: The authors identified from the Internet the main digital platforms that could easily be adopted in low-middle income countries. They selected free/low-cost mobile content with high educational impact. RESULTS: The platforms that were identified as fulfilling the characteristics described above are WFNS Young Neurosurgeons Forum Stream, Brainbook, NeuroMind, UpSurgeOn, The Neurosurgical Atlas, Touch surgery, The 100 UCLA Subjects in Neurosurgery, Neurosurgery Survival Guide, EANS (European Association of Neurosurgical Societies) Academy, Neurosurgical.TV, 3D Neuroanatomy, The Rhoton Collection, and Hinari. These platforms consist of webinars, 3D interactive neuroanatomy and neurosurgery content, videos, and e-learning programs supported by neurosurgical associations or journals. CONCLUSIONS: Digital education is an emerging tool for contributing to the spread of information in the neurosurgical community. The continuous improvement in the quality of content will rapidly increase the scientific validity of digital programs. In conclusion, the fast and easy access to digital resources could contribute to promote neurosurgical education in countries with limited facilities.

The challenges and opportunities of global neurosurgery in East Africa: the Neurosurgery Education and Development model.

OBJECTIVE: The objective of this study was to describe the experience of a volunteering neurosurgeon during an 18-week stay at the Neurosurgery Education and Development (NED) Institute and to report the general situation regarding the development of neurosurgery in Zanzibar, identifying the challenges and opportunities and explaining the NED Foundation's model for safe practice and sustainability. METHODS: The NED Foundation deployed the volunteer neurosurgeon coordinator (NC) for an 18-week stay at the NED Institute at the Mnazi Mmoja Hospital, Stonetown, Zanzibar. The main roles of the NC were as follows: management of patients, reinforcement of weekly academic activities, coordination of international surgical camps, and identification of opportunities for improvement. The improvement opportunities were categorized as clinical, administrative, and sociocultural and were based on observations made by the NC as well as on interviews with local doctors, administrators, and government officials. RESULTS: During the 18-week period, the NC visited 460 patients and performed 85 surgical procedures. Four surgical camps were coordinated on-site. Academic activities were conducted weekly. The most significant challenges encountered were an intense workload, deficient infrastructure, lack of self-confidence among local physicians, deficiencies in technical support and repairs of broken equipment, and lack of guidelines. Through a series of interviews, the sociocultural factors influencing the NED Foundation's intervention were determined. Factors identified for success were the activity of neurosurgical societies in East Africa; structured pan-African neurosurgical training; the support of the Foundation for International Education in Neurological Surgery (FIENS) and the College of Surgeons of East, Central and Southern Africa (COSECSA); motivated personnel; and the Revolutionary Government of Zanzibar's willingness to collaborate with the NED Foundation. CONCLUSIONS: International collaboration programs should balance local challenges and opportunities in order to effectively promote the development of neurosurgery in East Africa. Support and endorsement should be sought to harness shared resources and experience. Determining the caregiving and educational objectives within the logistic, administrative, social, and cultural framework of the target hospital is paramount to success.

Impact of Patients' Income on Stroke Prognosis.

BACKGROUND: For patients diagnosed with stroke, the association between socioeconomic status and patient outcomes is poorly understood. Our objective was to define the impact of patients' socioeconomic status on their prognosis after stroke in the United States. METHODS: Utilizing the Nationwide Inpatient Sample, we identified discharges involving a diagnosis of stroke from 2008 to 2013. Cohort was dichotomized to low-income patients (L-patients) and not-low-income patients (NL-patients). Z-test statistic was used to test the impact of income on stroke outcome. RESULTS: The reported annual total in-hospital mortality for L-patients and NL-patients diagnosed with stroke at U.S. hospitals decreased significantly during the study period (P < .001). The mortality of L-patients decreased significantly from 1759 (4.16%) to 955 (2.54%) during study period. Similarly, NL-patients' mortality decreased significantly from 4818 (4.52%) to 2300 (2.47%) during the same period. The difference between the annual total in-hospital mortality for L-patients and NL-patients due to stroke was statistically significant throughout the entire study period (P < .0001). Notably, from 2008 to 2013, the annual total routine discharges, annual total discharges to short-term hospital, annual total discharges to another institution, and annual total discharges to home health care were statistically significantly different between the 2 populations of patients (P < .0001). CONCLUSIONS: Socioeconomic status has an impact on patient outcome after treatment of stroke in hospitals in the United States. Further study is needed to investigate the etiology of these differences between patients' socioeconomic status and their clinical outcomes after stroke.

[Competency-based Neurosurgery Residency Programme]. / El nuevo programa de Residencia en Neurocirugía basado en competencias.

A programme proposal for competency-based Neurosurgery training adapted to the specialization project is presented. This proposal has been developed by a group of neurosurgeons commissioned by the SENEC (Spanish Society of Neurosurgery) and could be modified to generate a final version that could come into force coinciding with the implementation of the specialization programme. This document aims to facilitate the test of the new programme included in the online version of our journal. DURATION OF THE PROGRAMME: Total training period is 6 years; initial 2 years belong to the surgery specialization and remaining 4 years belong to core specialty period. STRUCTURE OF THE PROGRAMME: It is a competency-based programmed based on the map used by the US Accreditation Council for Graduate Medical Education (ACGME) including the following domains of clinical competency: Medical knowledge, patient care, communication skills, professionalism, practice-based learning and improvement, health systems, interprofessional collaboration and professional and personal development. Subcompetencies map in the domains of Knowledge and Patient care (including surgical competencies) was adapted to the one proposed by AANS and CNS (annex 1 of the programme). A subcompetency map was also used for the specialization rotations. INSTRUCTION METHODS: Resident's training is based on personal study (self-learning) supported by efficient use of information sources and supervised clinical practice, including bioethical instruction, clinical management, research and learning techniques. EVALUATION METHODS: Resident evaluation proposal includes, among other instruments, theoretical knowledge tests, objective and structured evaluation of the level of clinical competency with real or standardised patients, global competency scales, 360-degree evaluation, clinical record audits, milestones for residents progress and self-assessment (annex 2). Besides, residents periodically assess the teaching commitment of the department's neurosurgeons and other professors participating in rotations, and annually assess the overall operation of the programme. Results of evaluations are registered, together with other relevant data, in the Resident's Book. PROGRAMME'S NATIONAL COMMITTEE: The creation of a Programme Committee directly attached to the SENEC (National Commission) that, aside from generating a final version of the programme, monitors its implementation (level of adherence and operation in the different departments), assumes the creation of test banks and the centralized administration of knowledge tests (in the middle of the residency and/or at the end of it) and centralizes information collected by tutors that could be used for re-accreditation of the services, is proposed.

What is the Philosophy of Neurosurgery? Systematic Review and Defining the Discipline.

INTRODUCTION: Despite centuries of joint investigation of philosophy and neurological interventions, a founding account for the philosophy of neurosurgery has yet to be rigorously constructed or defended. This paper reviews recent work on the philosophy of neurosurgery, spanning metaphysics, epistemology, and value theory, to establish a framework and clinical relevance for study in the philosophy of neurosurgery. METHODS: A systematic review of an online database was conducted using the broad search terms, "Philosophy AND (Neurosurgery OR Neurological Surgery)." Records were included if they demonstrated relevance to the philosophy of neurosurgery and analytical rigor, but were excluded if solely legal, clinical, or ethical principles were considered without substantive discussion of underlying ethical frameworks and philosophical principles. RESULTS: Of 8025 candidates from online and print records, 16 records (14 from online sources and 2 from an edited volume) met inclusion criteria for the systematic review. Three dealt with metaphysics, 3 dealt with epistemology, 4 dealt with value theory, 5 dealt with metaphysics/epistemology, and 1 dealt with value theory/metaphysics. Questions of free will, consciousness, personal identity, neurosurgical knowledge, ascription of other minds, deontology, and minimalism, among others, were considered. DISCUSSION: Based on identified studies, the philosophy of neurosurgery is defined as the discipline of rigorously and methodically addressing metaphysical, epistemological, and value-theoretic questions arising from physically intervening in the nervous system. We discuss future directions for questions within the philosophy of neurosurgery and consider their relevance for patient care and the practice of neurosurgery.

The Glymphatic System and Subarachnoid Lymphatic-Like Membrane: Recent Developments in Cerebrospinal Fluid Research.

BACKGROUND: Cerebrospinal fluid (CSF) circulates throughout the ventricles, cranial and spinal subarachnoid spaces, and central spinal cord canal. CSF protects the central nervous system through mechanical cushioning, regulation of intracranial pressure, regulation of metabolic homeostasis, and provision of nutrients. Recently, investigators have characterized the glial-lymphatic (glymphatic) system, the analog of the lymphatic system in the central nervous system, and described a fourth meningeal layer; the subarachnoid lymphatic-like membrane (SLYM)relevant to the CSF. METHODS: A narrative review was conducted. RESULTS: In this review, we summarize these advances. We describe the development of the original model, controversies, a revised model, and a new conceptual framework. We characterize the biological functions, influence of sleep-wake cycles, and effect of aging with relevance to the glymphatic system. We highlight the role of the glymphatic system in Alzheimer's disease, idiopathic normal pressure hydrocephalus, ischemic stroke, subarachnoid hemorrhage, and traumatic brain injury. Next, we characterize the structure and role of the SLYM. Finally, we explore the relevance of the glymphatic system and SLYM to neurosurgery. CONCLUSIONS: This manuscript will inform clinicians and scientists regarding preclinical and translational advances in the understanding of the structure, dynamics, and function of the CSF.

Navigating the Neurosurgery Match Process: Insights from the National Resident Matching Program - Program Director Surveys.

OBJECTIVE: Neurosurgery is one of the most competitive specialties, and navigating the match process is often challenging for aspiring applicants. Here, we analyze insights from the National Resident Matching Program Director Surveys, illustrating evolving trends in applicant selection for interviews and for the ranking process, and providing a comparison with other specialties. METHODS: We evaluated 7 surveys administered from 2012 to 2022. Six biennial surveys reported on factors influencing interview and ranking processes, while all 7 surveys included data about the program director (PD)'s attitude toward United States Medical Licensing Examination (USMLE) test scores. RESULTS: The response rate of PDs decreased over the years. The most cited factor for interviews included specialty-specific recommendation letters (95%), USMLE Step 1 scores (91%), and interest in research (78%). A recent decline in emphasis on USMLE Step 1 scores coincided with a growing reliance on USMLE Step 2 scores. Award in basic science held significant esteem to a subset of programs. Personal characteristics dominated for ranking, with faculty interaction (89%), interpersonal skills (89%), and house staff interaction (85%) being the most important. Yet, PDs reported a difficulty in assessing interpersonal skills through virtual interviews. CONCLUSIONS: Our analysis revealed the pervasive importance of specialized endorsements and academic achievements when screening applicants for the interview process. A shift in emphasis toward the USMLE Step 2 became apparent. Personal characteristics, on the other hand, seemed crucial to make a match and rank high among the pool of interviewed applicants. We uncovered difficulties in assessing these characteristics through virtual interviews.

Efficacy of prophylactic use of intraoperative vancomycin powder in preventing surgical site infection in neurological surgeries in Irrua, Nigeria: A randomized controlled study.

PURPOSE: The objective was to determine the efficacy of intraoperative vancomycin powder in preventing SSIs in neurological surgeries. METHODS: A prospective randomized controlled study of patients who had clean cranial and non-implant spine surgeries at the Irrua Specialist Teaching Hospital, Irrua, Nigeria from February 1, 2021 to January 31, 2022. Patients were randomized into two groups. Group A patients had prophylactic intraoperative vancomycin powder applied to the surgical bed before wound closure while group B patients did not. Patients in both groups were followed up for 30 days post-operatively for evidence of SSI. The occurrence of SSIs was determined using clinical and laboratory parameters. Baseline characteristics, operative details, rates of wound infection, and microbiological data for each case were recorded. Data was analyzed using Statistical Package for Scientific Solution (SPSS) version 23 software. RESULTS: Forty-two patients were randomized into 2 groups of 21 patients each. The age range of the patients was 20 to 80 years. The majority of the patients were males (32 out of 42). The mean age of patients in group A was 48.05 ± 17.03 years, while group B had a mean age of 45.95 ± 19.14 years. The mean Body Mass Index of patients in groups A and B were 23.92 ± 5.21 and 23.21 ± 3.99 respectively. Seven out of 21 patients (33.3 %) in the control group ( group B) had superficial SSIs while no patient in the experimental group had SSI, p-value < 0.05. The organisms cultured were Klebsiella pneumoniae, Pseudomonas aeruginosa, and Staphylococcus aureus. CONCLUSION: Intraoperative vancomycin powder was effective in reducing the rate of SSIs following neurological surgeries and without adverse drug reactions.

Neurosurgery residency match for international medical graduates in the United States.

OBJECTIVE: Training of international medical graduates (IMGs) offers opportunities for the US neurosurgery community to engage the global talent pool and impact national and international healthcare. Here, the authors analyzed the time trend of IMGs matching into US neurosurgery programs and identified potential opportunities for enhancing IMG engagement. METHODS: The authors analyzed the National Resident Matching Program (NRMP) match results, NRMP program director (PD) surveys, and applicant surveys from 2013 to 2022. Regression methods were used to analyze time trends. RESULTS: Between 2013 and 2022, the number of US neurosurgery residency positions increased by 17.6% (from 204 to 240). During this period, the percentage of IMGs matching into neurosurgery increased from 3.5% to 7%, translating into a 6.8% increase in the likelihood of a successful IMG match per year (95% CI 0.3%-13.8%, p = 0.042). The likelihoods of a successful match for US MDs and IMGs scoring > 260 on the USMLE Step 1 were > 90% and approximately 55%, respectively. In PD surveys, approximately 90% of PDs indicated that they seldom/never interview or rank IMGs. In terms of factors that influenced the PD decision for interviewing/ranking, IMGs are disadvantaged in several categories, including the ability to secure an audition elective/rotation, and proper letters of recommendation, as well as the influence of the culture on the preconceived perception of poor interpersonal skills. CONCLUSIONS: The number of IMGs matching successfully in neurosurgery has increased marginally during the past decade. The authors outline the challenges that IMGs encounter in this process and suggest strategies for considerations of IMG training in NRMP-associated institutions.

Augmenting Career Longevity: An Analysis of Ergonomics Training Among 134 Neurological Surgeons.

BACKGROUND: Work-related pain among neurosurgeons remains understudied, yet can have long-term consequences which affect operative efficiency and efficacy, career longevity, and life outside of work. OBJECTIVE: This study provides insight into the extent of pain experienced by neurosurgeons and the effect of ergonomics training on pain. METHODS: An online survey pertaining to ergonomics and pain was sent to all neurosurgeons on the Council of State Neurosurgical Societies (CSNS) email distribution list. Statistical comparisons of age groups against pain levels and ergonomics training against pain levels, as well as multivariate linear regression of demographics, training, and operating factors against pain levels were performed. RESULTS: One hundred and thirty-four neurosurgeons responded to the survey. The mean average severity of pain across respondents was 3.3/10 and the mean peak severity of pain was 5.1/10. Among the reported peak pain severity scores, neurosurgeons with 21-30 years of operating experience had significantly higher pain scores than those with 11-20 years of experience (mean 6.2 vs. 4.2; P < 0.05), while neurosurgeons with more than 30 years of experience had significantly less pain than those with 21-30 years of experience (mean 4.4 vs. 6.2, P = 0.005). Training in ergonomics did not significantly improve respondents' reported peak or mean pain severities (17.9% reported having ergonomics training). CONCLUSIONS: Ergonomics training did not appear to make a difference in neurosurgeons' pain severities. This may signify a need to optimize ergonomics pedagogy to achieve observable benefits.

The Committee on Advanced Subspecialty Training-accredited postgraduate neurosurgery fellowship application experience: a national survey.

OBJECTIVE: The neurosurgery fellowship application process is heterogenous. Therefore, the authors conducted a survey of individuals graduating from Committee on Advanced Subspecialty Training (CAST)-accredited fellowships in the past 5 years to examine 1) experiences with the fellowship application process, 2) perspectives on the process, 3) reasons for pursuing a given subspecialty and fellowship, and 4) post-fellowship practices. METHODS: A survey querying demographics, experiences with and perspectives on the fellowship application process, and factors contributing to the pursuit of a given fellowship was distributed to individuals who had graduated from CAST-accredited fellowships in the past 5 years. The survey response period was May 22, 2021-June 22, 2021. RESULTS: Of 273 unique individuals who had graduated from CAST-accredited fellowships in the past 5 years, 65 (29.7%) were included in this analysis. The most common postgraduate year (PGY) during which respondents applied for fellowship positions was PGY5 (43.8%), whereas the most common training level at which respondents accepted a fellowship position was PGY6 (46.9%), with a large degree of variability for both (range PGY4-PGY7). Only 43.1% respondents reported an application deadline for their fellowship. A total of 77.4% respondents received 1-2 fellowship position offers, and 13.4% indicated that there was a match process. In total, 64.5% respondents indicated that the fellowship offer timeline was mostly or very asynchronous. The time frame for applicants to decline or accept a fellowship offer was heterogeneous and mismatched among institutions. Respondents agreed that a more standardized application timeline would be beneficial (median response "agree"), and 83.1% of respondents indicated that PGY5 or PGY6 was the appropriate time to interview for a fellowship. CONCLUSIONS: Respondents reported heterogeneous experiences in applying for a fellowship, indicated that a standardized application timeline including interviews at PGY5 or PGY6 would be beneficial, and preferred streamlining the fellowship application process.

Innovative growth and development of a neurological surgery residency cadaveric skull base simulation training program: A single institution experience.

OBJECTIVE: Neurosurgical cadaveric and simulation training is a valuable opportunity for residents and fellows to develop as neurosurgeons, further neuroanatomy knowledge, and develop decision-making and technical expertise. The authors describe the growth and development of Oregon Health & Science University (OHSU) Department of Neurological Surgery (NSG) resident hands-on simulation skull base course and provide details of course layout and setup. METHODS: A three-part surgical simulation series was created to provide training in cadaveric skull base procedures. Course objectives were outlined for participants. Residents participated in NSG hands-on simulation courses (years 2015-2020) and completed annual course curriculum and anonymous course evaluations, which included free text reviews. Courses were evaluated by Likert scale analysis within Python, and free text was quantified using Valence Aware Dictionary for sEntiment Reasoning (VADER). Descriptive statistics were calculated and plotted using Python's Seaborn and Matplotlib library modules. RESULTS: Analysis included 162 skull base (anterior fossa, middle fossa and lateral, and endoscopic endonasal-based) simulation course evaluations. Resident responses were overwhelmingly positive. Likert responses demonstrated high average responses for each question (4.62 ± 0.56 and above). A positive attitude about simulation courses is supported by an average compound sentiment value of 0.558 ± 0.285. CONCLUSION: This is the first time Likert responses and sentiment analysis have been used to demonstrate how neurosurgical residents view a comprehensive, multi-year hands-on simulation training program. We hope the information presented serves as a guide for other institutions to develop their own residency educational curriculum in cadaveric skull base procedures.