David P. Darrow, Stephen J. Haines, and Andrew W. Grande
Sangami Pugazenthi, Gabrielle W. Johnson, Hedwig Lee, and Jennifer M. Strahle
OBJECTIVE
Although women account for 50% of medical school graduates, less than 30% of neurosurgery residency applicants and less than 10% of neurosurgeons are female. In order to diversify the field of neurosurgery and recruit more women, it is necessary to understand why there is a disproportionately low entry rate into neurosurgery by female medical students. Factors contributing to specialty decision-making and perceptions of neurosurgery among medical students and residents, specifically differences by gender, have not been studied. The authors aimed to investigate these differences using quantitative and qualitative methods.
METHODS
A Qualtrics survey was administered at the authors’ institution to all medical students and resident physicians to assess factors influencing medical specialty decision-making and perceptions of neurosurgery. Likert scale responses converted to numerical values on a 5-point scale were analyzed with the Mann-Whitney U-test. The chi-square test was performed on binary responses. Semistructured interviews were conducted in a subset of survey respondents and were analyzed by using the grounded theory method.
RESULTS
Of the 272 survey respondents, 48.2% were medical students and 61.0% were female. When making specialty decisions, female medical students considered maternity/paternity leave more (p = 0.028) than their male counterparts. Female medical students were more hesitant toward neurosurgery due to maternity/paternity needs (p = 0.031) and the technical skill required (p = 0.020) than male medical students. Across both genders, the majority of medical students were hesitant toward neurosurgery due to opportunities for work/life integration (93%), length of training (88%), malignancy of the field (76%), and perceived happiness of the people in the field (76%). Female residents indicated they were more likely than male residents to consider the perceived happiness of the people in the field (p = 0.003), shadowing experiences (p = 0.019), and elective rotations (p = 0.004) when making specialty decisions. Two major themes emerged from the semistructured interviews: 1) maternity needs were more of a concern for women and 2) length of training was a concern for many individuals.
CONCLUSIONS
Compared with their male counterparts, female students and residents consider different factors and experiences when choosing a medical specialty and have different perceptions of neurosurgery. Exposure to and education within neurosurgery, specifically maternity needs, may help address hesitancy in pursuing a neurosurgical career among female medical students. However, cultural and structural factors may need to be addressed within neurosurgery in order to ultimately increase representation of women.
Sangami Pugazenthi, Gabrielle W. Johnson, Hedwig Lee, and Jennifer M. Strahle
OBJECTIVE
Although individuals underrepresented in medicine (URM) make up 33% of the United States population, only 12.6% of medical school graduates identify as URM; the same percentage of URM students comprises neurosurgery residency applicants. More information is needed to understand how URM students are making specialty decisions and their perceptions of neurosurgery. The authors aimed to evaluate the differences between URM and non-URM medical students and residents in terms of the factors that contribute to specialty decision-making and perceptions of neurosurgery.
METHODS
A survey was administered to all medical students and resident physicians at a single Midwestern institution to assess factors influencing medical student specialty decision-making and perceptions of neurosurgery. Likert scale responses converted to numerical values on a 5-point scale (strongly agree was the high score of 5) were analyzed with the Mann-Whitney U-test. The chi-square test was performed on the binary responses to examine associations between categorical variables. Semistructured interviews were conducted and analyzed using the grounded theory method.
RESULTS
Of 272 respondents, 49.2% were medical students, 51.8% were residents, and 11.0% identified as URM. URM medical students considered research opportunities more than non-URM medical students in specialty decision-making (p = 0.023). When specialty decision-making factors were assessed, URM residents less strongly considered the technical skill required (p = 0.023), their perceived fit in the field (p < 0.001), and seeing people like them in the field (p = 0.010) than their non-URM counterparts when making specialty decisions. Within both medical student and resident respondent cohorts, the authors found no significant differences between URM and non-URM respondents in terms of their specialty decision-making being affected by medical school experiences such as shadowing, elective rotations, family exposure, or having a mentor in the field. URM residents were more concerned about the opportunity to work on health equity issues in neurosurgery than non-URM residents (p = 0.005). The predominant theme that emerged from interviews was the need for more intentional efforts to recruit and retain URM individuals in medicine and specifically neurosurgery.
CONCLUSIONS
URM students may make specialty decisions differently than non-URM students. URM students were more hesitant toward neurosurgery due to their perceived lack of opportunity for health equity work in neurosurgery. These findings further inform optimization of both new and existing initiatives to improve URM student recruitment and retention in neurosurgery.
Shotaro Ogawa and Hideki Ogiwara
OBJECTIVE
Untethering surgery for a tight filum terminale is a common treatment with considerable efficacy and safety. On the other hand, retethering has been reported to occur. One of the major mechanisms of retethering is adherence of the cut end of the sectioned filum to the midline dorsal dural surface. To prevent retethering, the authors sectioned a filum terminale at the rostral level to the dural incision to keep the distance between the cut end of the sectioned filum and the dural incision and investigated whether this procedure decreased the occurrence of retethering.
METHODS
Among the patients who underwent untethering surgery for a tight filum terminale between 2012 and 2016, patients followed up more than 5 years were included in the study. Symptoms, comorbid malformations, preoperative imaging, surgical details, perioperative complications, and long-term outcomes were reviewed retrospectively.
RESULTS
Retrospective data for a total of 342 cases were included. The median age at surgery was 11 months (range 3–156 months). Preoperative MRI revealed 254 patients (74.3%) had a low-set conus. There were 142 patients (41.5%) with filar lipoma and 42 patients (12.3%) with terminal cyst. Syringomyelia was found in 29 patients (8.5%). In total, 246 patients (71.9%) were symptomatic and 96 patients (28.1%) were asymptomatic. There were no perioperative complications that required surgical intervention or prolonged hospitalization. The mean postoperative follow-up was 88 months (range 60–127 months). There were 4 patients (1.2%) with retethering who presented with bladder and bowel dysfunction. The mean time from initial untethering to retethering was 54 months (range 36–80 months). All 4 patients underwent untethering surgery, and preoperative symptoms resolved in 3 patients.
CONCLUSIONS
The retethering rate after untethering surgery for a tight filum terminale in our series was lower than those in previously reported studies. Sectioning the filum terminale at the rostral level to the dural incision was considered an effective way to prevent retethering.
Xun Wu, Haixiao Liu, Rongjun Zhang, Yong Du, Yaning Cai, Zhijun Tan, Feng Liu, Fei Gao, Hui Zhang, Gaoyang Zhou, Feifei Sun, Ruixi Fan, Ping Wang, Lei Wang, Shunnan Ge, Tianzhi Zhao, Guoqiang Xie, Dongbo Li, Yan Qu, and Wei Guo
OBJECTIVE
Spontaneous basal ganglia hemorrhage is a common type of intracerebral hemorrhage (ICH) with no definitive treatment. Minimally invasive endoscopic evacuation is a promising therapeutic approach for ICH. In this study the authors examined prognostic factors associated with long-term functional dependence (modified Rankin Scale [mRS] score ≥ 4) in patients who had undergone endoscopic evacuation of basal ganglia hemorrhage.
METHODS
In total, 222 consecutive patients who underwent endoscopic evacuation between July 2019 and April 2022 at four neurosurgical centers were enrolled prospectively. Patients were dichotomized into functionally independent (mRS score ≤ 3) and functionally dependent (mRS score ≥ 4) groups. Hematoma and perihematomal edema (PHE) volumes were calculated using 3D Slicer software. Predictors of functional dependence were assessed using logistic regression models.
RESULTS
Among the enrolled patients, the functional dependence rate was 45.50%. Factors independently associated with long-term functional dependence included female sex, older age (≥ 60 years), Glasgow Coma Scale score ≤ 8, larger preoperative hematoma volume (OR 1.02), and larger postoperative PHE volume (OR 1.03, 95% CI 1.01–1.05). A subsequent analysis evaluated the effect of stratified postoperative PHE volume on functional dependence. Specifically, patients with large (≥ 50 to < 75 ml) and extra-large (≥ 75 to 100 ml) postoperative PHE volumes had 4.61 (95% CI 0.99–21.53) and 6.75 (95% CI 1.20–37.85) times greater likelihood of long-term dependence, respectively, than patients with a small postoperative PHE volume (≥ 10 to < 25 ml).
CONCLUSIONS
A large postoperative PHE volume is an independent risk factor for functional dependence among basal ganglia hemorrhage patients after endoscopic evacuation, especially with postoperative PHE volume ≥ 50 ml.
Anthony L. Asher, Regis W. Haid, Ann R. Stroink, Giorgos D. Michalopoulos, A. Yohan Alexander, Daniel Zeitouni, Andrew K. Chan, Michael S. Virk, Steven D. Glassman, Kevin T. Foley, Jonathan R. Slotkin, Eric A. Potts, Mark E. Shaffrey, Christopher I. Shaffrey, Paul Park, Cheerag Upadhyaya, Domagoj Coric, Luis M. Tumialán, Dean Chou, Kai-Ming G. Fu, John J. Knightly, Katie O. Orrico, Michael Y. Wang, Erica F. Bisson, Praveen V. Mummaneni, and Mohamad Bydon
OBJECTIVE
The Quality Outcomes Database (QOD) was established in 2012 by the NeuroPoint Alliance, a nonprofit organization supported by the American Association of Neurological Surgeons. Currently, the QOD has launched six different modules to cover a broad spectrum of neurosurgical practice—namely lumbar spine surgery, cervical spine surgery, brain tumor, stereotactic radiosurgery (SRS), functional neurosurgery for Parkinson’s disease, and cerebrovascular surgery. This investigation aims to summarize research efforts and evidence yielded through QOD research endeavors.
METHODS
The authors identified all publications from January 1, 2012, to February 18, 2023, that were produced by using data collected prospectively in a QOD module without a prespecified research purpose in the context of quality surveillance and improvement. Citations were compiled and presented along with comprehensive documentation of the main study objective and take-home message.
RESULTS
A total of 94 studies have been produced through QOD efforts during the past decade. QOD-derived literature has been predominantly dedicated to spinal surgical outcomes, with 59 and 22 studies focusing on lumbar and cervical spine surgery, respectively, and 6 studies focusing on both. More specifically, the QOD Study Group—a research collaborative between 16 high-enrolling sites—has yielded 24 studies on lumbar grade 1 spondylolisthesis and 13 studies on cervical spondylotic myelopathy, using two focused data sets with high data accuracy and long-term follow-up. The more recent neuro-oncological QOD efforts, i.e., the Tumor QOD and the SRS Quality Registry, have contributed 5 studies, providing insights into the real-world neuro-oncological practice and the role of patient-reported outcomes.
CONCLUSIONS
Prospective quality registries are an important resource for observational research, yielding clinical evidence to guide decision-making across neurosurgical subspecialties. Future directions of the QOD efforts include the development of research efforts within the neuro-oncological registries and the American Spine Registry—which has now replaced the inactive spinal modules of the QOD—and the focused research on high-grade lumbar spondylolisthesis and cervical radiculopathy.
Emma Min Shuen Toh, Boshen Yan, Isis Claire Lim, Dylan Michael Yap, Wen Jun Wee, Kai Jie Ng, Vincent Diong Weng Nga, Mehul Motani, and Mervyn Jun Rui Lim
OBJECTIVE
Intracranial pressure (ICP) monitoring is a widely utilized and essential tool for tracking neurosurgical patients, but there are limitations to the use of a solely ICP-based paradigm for guiding management. It has been suggested that ICP variability (ICPV), in addition to mean ICP, may be a useful predictor of neurological outcomes, as it represents an indirect measure of intact cerebral pressure autoregulation. However, the current literature regarding the applicability of ICPV shows conflicting associations between ICPV and mortality. Thus, the authors aimed to investigate the effect of ICPV on intracranial hypertensive episodes and mortality using the eICU Collaborative Research Database version 2.0.
METHODS
The authors extracted from the eICU database 1,815,676 ICP readings from 868 patients with neurosurgical conditions. ICPV was computed using two methods: the rolling standard deviation (RSD) and the absolute deviation from the rolling mean (DRM). An episode of intracranial hypertension was defined as at least 25 minutes of ICP > 22 mm Hg in any 30-minute window. The effects of mean ICPV on intracranial hypertension and mortality were computed using multivariate logistic regression. A recurrent neural network with long short-term memory was used for time-series predictions of ICP and ICPV to prognosticate future episodes of intracranial hypertension.
RESULTS
A higher mean ICPV was significantly associated with intracranial hypertension using both ICPV definitions (RSD: aOR 2.82, 95% CI 2.07–3.90, p < 0.001; DRM: aOR 3.93, 95% CI 2.77–5.69, p < 0.001). ICPV was significantly associated with mortality in patients with intracranial hypertension (RSD: aOR 1.28, 95% CI 1.04–1.61, p = 0.026, DRM: aOR 1.39, 95% CI 1.10–1.79, p = 0.007). In the machine learning models, both definitions of ICPV achieved similarly good results, with the best F1 score of 0.685 ± 0.026 and an area under the curve of 0.980 ± 0.003 achieved with the DRM definition over 20 minutes.
CONCLUSIONS
ICPV may be useful as an adjunct for the prognostication of intracranial hypertensive episodes and mortality in neurosurgical critical care as part of neuromonitoring. Further research on predicting future intracranial hypertensive episodes with ICPV may help clinicians react expediently to ICP changes in patients.
Steven D. Glassman, Leah Y. Carreon, Anthony L. Asher, Ayushmita De, Kyle Mullen, Kimberly R. Porter, Christopher I. Shaffrey, John J. Knightly, Kevin T. Foley, Todd J. Albert, Darrel S. Brodke, David W. Polly Jr., and Mohamad Bydon
OBJECTIVE
Clear diagnostic delineation is necessary for the development of a strong evidence base in lumbar spinal surgery. Experience with existing national databases suggests that International Classification of Diseases, Tenth Edition (ICD-10) coding is insufficient to support that need. The purpose of this study was to assess agreement between surgeon-specified diagnostic indication and hospital-reported ICD-10 codes for lumbar spine surgery.
METHODS
Data collection for the American Spine Registry (ASR) includes an option to denote the surgeon’s specific diagnostic indication for each procedure. For cases treated between January 2020 and March 2022, surgeon-delineated diagnosis was compared with the ICD-10 diagnosis generated by standard ASR electronic medical record data extraction. For decompression-only cases, the primary analysis focused on the etiology of neural compression as determined by the surgeon versus that determined on the basis of the related ICD-10 codes extracted from the ASR database. For lumbar fusion cases, the primary analysis compared structural pathology, which may have required fusion, as determined by the surgeon versus that determined on the basis of the extracted ICD-10 codes. This allowed for identification of agreement between surgeon delineation and extracted ICD-10 codes.
RESULTS
In 5926 decompression-only cases, agreement between the surgeon and ASR ICD-10 codes was 89% for spinal stenosis and 78% for lumbar disc herniation and/or radiculopathy. Both the surgeon and database indicated no structural pathology (i.e., none) suggesting the need for fusion in 88% of cases. In 5663 lumbar fusion cases, agreement was 76% for spondylolisthesis but poor for other diagnostic indications.
CONCLUSIONS
Agreement between surgeon-specified diagnostic indication and hospital-reported ICD-10 codes was best for patients who underwent decompression only. In the fusion cases, agreement with ICD-10 codes was best in the spondylolisthesis group (76%). In cases other than spondylolisthesis, agreement was poor due to multiple diagnoses or lack of an ICD-10 code that reflected the pathology. This study suggested that standard ICD-10 codes may be inadequate to clearly define the indications for decompression or fusion in patients with lumbar degenerative disease.
Joshua S. Catapano, Kavelin Rumalla, Visish M. Srinivasan, Dimitri Benner, Ethan A. Winkler, Peter M. Lawrence, Kristen Larson Keil, and Michael T. Lawton
OBJECTIVE
Anatomical taxonomy is a practical tool to successfully guide clinical decision-making for patients with brain arteriovenous malformations and brainstem cavernous malformations (CMs). Deep cerebral CMs are complex, difficult to access, and highly variable in size, shape, and position. The authors propose a novel taxonomic system for deep CMs in the thalamus based on clinical presentation (syndromes) and anatomical location (identified on MRI).
METHODS
The taxonomic system was developed and applied to an extensive 2-surgeon experience from 2001 through 2019. Deep CMs involving the thalamus were identified. These CMs were subtyped on the basis of the predominant surface presentation identified on preoperative MRI. Six subtypes among 75 thalamic CMs were defined: anterior (7/75, 9%), medial (22/75, 29%), lateral (10/75, 13%), choroidal (9/75, 12%), pulvinar (19/75, 25%), and geniculate (8/75, 11%). Neurological outcomes were assessed using modified Rankin Scale (mRS) scores. A postoperative score ≤ 2 was defined as a favorable outcome and > 2 as a poor outcome. Clinical and surgical characteristics and neurological outcomes were compared among subtypes.
RESULTS
Seventy-five patients underwent resection of thalamic CMs and had clinical and radiological data available. Their mean age was 40.9 (SD 15.2) years. Each thalamic CM subtype was associated with a recognizable constellation of neurological symptoms. The common symptoms were severe or worsening headaches (30/75, 40%), hemiparesis (27/75, 36%), hemianesthesia (21/75, 28%), blurred vision (14/75, 19%), and hydrocephalus (9/75, 12%). The thalamic CM subtype determined the selection of surgical approach. A single approach was associated with each subtype for most patients. The main exception to this paradigm was that in the surgeons’ early experience, pulvinar CMs were resected through a superior parietal lobule–transatrial approach (4/19, 21%), which later evolved to the paramedian supracerebellar-infratentorial approach (12/19, 63%). Relative outcomes implied by mRS scores were unchanged or improved in most patients (61/66, 92%) postoperatively.
CONCLUSIONS
This study confirms the authors’ hypothesis that this taxonomy for thalamic CMs can meaningfully guide the selection of surgical approach and resection strategy. The proposed taxonomy can increase diagnostic acumen at the patient bedside, help identify optimal surgical approaches, enhance the clarity of clinical communications and publications, and improve patient outcomes.
