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Nathan A. Shlobin, Andrew Wang, H. Westley Phillips, Han Yan, George M. Ibrahim, Lior M. Elkaim, Shuang Wang, Xiaoyan Liu, Lixin Cai, Dang K. Nguyen, Aria Fallah, and Alexander G. Weil

OBJECTIVE

The prevalence of long-term postoperative sensorimotor deficits in children undergoing perirolandic resective epilepsy surgery is unclear. The risk of developing these deficits must be weighed against the potential reduction in seizure frequency after surgery. In this study, the authors investigated the prevalence of sensorimotor deficits after resective surgery at ≥ 1 year postoperatively.

METHODS

A systematic review and individual patient data meta-analysis was conducted using PubMed, Embase, and Scopus databases. Subgroups of patients were identified and categorized according to their outcomes as follows: group A patients were denoted as seizure free with no postoperative sensorimotor deficits; group B patients experienced seizure recurrence with no deficit; group C patients were seizure free with deficits; and group D patients were not seizure free and with deficits. Rates of sensory deficits were examined in patients undergoing postcentral gyrus resection, and rates of motor deficits were aggregated in patients undergoing precentral gyrus resection.

RESULTS

Of 797 articles resulting from the database searches, 6 articles including 164 pediatric patients at a mean age of 7.7 ± 5.2 years with resection for drug-resistant perirolandic epilepsy were included in the study. Seizure freedom was observed in 118 (72.9%) patients at a mean follow-up of 3.4 ± 1.8 years. In total, 109 (66.5%) patients did not develop sensorimotor deficits at last follow-up, while 55 (33.5%) had permanent deficits. Ten (14.3%) of 70 patients with postcentral gyrus resection had permanent sensory deficits. Of the postcentral gyrus resection patients, 41 (58.6%) patients were included in group A, 19 (27.1%) in group B, 7 (10.0%) in group C, and 3 (4.3%) in group D. Forty (37.7%) of 106 patients with precentral resections had permanent motor deficits. Of the precentral gyrus resection patients, 50 (47.2%) patients were in group A, 16 (15.1%) in group B, 24 (22.6%) in group C, and 16 (15.1%) in group D. Patients without focal cortical dysplasia were more likely to have permanent motor deficits relative to those with focal cortical dysplasia in the precentral surgery cohort (p = 0.02).

CONCLUSIONS

In total, 58.6% of patients were seizure free without deficit, 27.1% were not seizure free and without deficit, 10.0% were seizure free but with deficit, and 4.3% were not seizure free and with deficit. Future studies with functional and quality-of-life data, particularly for patients who experience seizure recurrence with no deficits (as in group B in the present study) and those who are seizure free with deficits (as in group C) after treatment, are necessary to guide surgical decision-making.

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Evgenii Belykh, Irakliy Abramov, Liudmila Bardonova, Ruchi Patel, Sarah McBryan, Lara Enriquez Bouza, Neil Majmundar, Xiaochun Zhao, Vadim A. Byvaltsev, Stephen A. Johnson, Amit Singla, Gaurav Gupta, Hai Sun, James K. Liu, Anil Nanda, Mark C. Preul, and Michael T. Lawton

OBJECTIVE

Microsurgical training remains indispensable to master cerebrovascular bypass procedures, but simulation models for training that accurately replicate microanastomosis in narrow, deep-operating corridors are lacking. Seven simulation bypass scenarios were developed that included head models in various surgical positions with premade approaches, simulating the restrictions of the surgical corridors and hand positions for microvascular bypass training. This study describes these models and assesses their validity.

METHODS

Simulation models were created using 3D printing of the skull with a designed craniotomy. Brain and external soft tissues were cast using a silicone molding technique from the clay-sculptured prototypes. The 7 simulation scenarios included: 1) temporal craniotomy for a superficial temporal artery (STA)–middle cerebral artery (MCA) bypass using the M4 branch of the MCA; 2) pterional craniotomy and transsylvian approach for STA-M2 bypass; 3) bifrontal craniotomy and interhemispheric approach for side-to-side bypass using the A3 branches of the anterior cerebral artery; 4) far lateral craniotomy and transcerebellomedullary approach for a posterior inferior cerebellar artery (PICA)–PICA bypass or 5) PICA reanastomosis; 6) orbitozygomatic craniotomy and transsylvian-subtemporal approach for a posterior cerebral artery bypass; and 7) extended retrosigmoid craniotomy and transcerebellopontine approach for an occipital artery–anterior inferior cerebellar artery bypass. Experienced neurosurgeons evaluated each model by practicing the aforementioned bypasses on the models. Face and content validities were assessed using the bypass participant survey.

RESULTS

A workflow for model production was developed, and these models were used during microsurgical courses at 2 neurosurgical institutions. Each model is accompanied by a corresponding prototypical case and surgical video, creating a simulation scenario. Seven experienced cerebrovascular neurosurgeons practiced microvascular anastomoses on each of the models and completed surveys. They reported that actual anastomosis within a specific approach was well replicated by the models, and difficulty was comparable to that for real surgery, which confirms the face validity of the models. All experts stated that practice using these models may improve bypass technique, instrument handling, and surgical technique when applied to patients, confirming the content validity of the models.

CONCLUSIONS

The 7 bypasses simulation set includes novel models that effectively simulate surgical scenarios of a bypass within distinct deep anatomical corridors, as well as hand and operator positions. These models use artificial materials, are reusable, and can be implemented for personal training and during microsurgical courses.

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Akshar H. Patel, Sione A. Ofa, Lacee K. Collins, Leland C. McCluskey Jr., William F. Sherman, and Mathew Cyriac

OBJECTIVE

With the use of anterior cervical discectomy and fusion (ACDF) expected to rise by 13.3% from 2020 to 2040, the increased usage of interbody cages with integral anterior fixation prompted a Centers for Medicare & Medicaid Services (CMS) review, which resulted in coding changes affecting anterior instrumentation documentation. CMS determined that Current Procedural Terminology (CPT) code 22845 should not be used to report integrated instrumentation (plate) with an interbody device, and if additional anterior instrumentation (e.g., plates and screws) is placed with an integrated interbody device, then a 59 modifier should be used. There is sparse literature examining the trends of ACDF without and with additional anterior instrumentation after the 2015 CMS audit. Therefore, this study aimed to evaluate the trends of single-level subaxial ACDF utilization from 2011 to 2019 to determine whether the 2015 CMS audit influenced the documented usage of additional anterior instrumentation.

METHODS

A retrospective cohort study was performed using the commercially available database PearlDiver. Patient records were queried from 2011 to 2019 for single-level subaxial ACDF without (CPT code 22551) and with (CPT codes 22551 + 22845) instrumentation. Cochran-Armitage trend analyses were performed to evaluate the hypothesis that ACDF with additional anterior instrumentation decreased over the given time period.

RESULTS

Between 2011 and 2019, the total number of single-level ACDFs decreased from 6202 to 4402. From 2011 to 2015, an average of 6240 patients per year underwent single-level subaxial ACDF; of those, 950 patients (15.2%) had ACDF without instrumentation and 5290 patients (84.8%) had ACDF with instrumentation. In 2016, the total number of single-level subaxial ACDFs decreased to 5525, with 1006 patients (18.2%) receiving no instrumentation and 4519 patients (81.8%) receiving instrumentation. From 2017 to 2019, an average of 4283 patients per year underwent a single-level subaxial ACDF; of these, 1280 (29.9%) had no instrumentation and 3003 (70.1%) had instrumentation (all p < 0.0001).

CONCLUSIONS

From 2015 to 2019, single-level ACDF without instrumentation significantly increased by 91.5% and ACDF with anterior instrumentation significantly decreased by 18.1%. The 2015 CMS audit of interbody cages and anterior instrumentation coding (CPT code 22845) may account for the decreased documentation of anterior instrumentation in the 9-year period. Understanding CMS auditing could help surgeons perceive changes in practice patterns that may lead to a more thorough evaluation of patient outcomes, cost, and overall value.

Open access

Sandeep Muram, Albert M. Isaacs, Nicholas Sader, Richard Holubkov, Annie Fong, John Conly, and Mark G. Hamilton

OBJECTIVE

Ventriculoperitoneal (VP) shunt insertion and revision surgeries are some of the most common procedures that are performed by neurosurgeons. Shunt infections within the adult population are associated with significant morbidity and mortality and rates remain high. The objective of the current study was to use quality improvement (QI) methodology to create a standardized infection prevention bundle aimed at reducing the rate of shunt infections.

METHODS

A prospective, single-center, single-surgeon QI study was undertaken. Patients were included if they were 18 years of age or older and were undergoing a VP shunt insertion or revision. The primary outcome of the study was the development of a shunt-related surgical site infection, within 1 year of surgery, as defined according to the Canadian Nosocomial Infection Surveillance Program guidelines. There was no standardized protocol prior to July 2013. A bundle coined as the Calgary Adult Shunt Infection Prevention Protocol (CASIPP) was implemented on July 1, 2013, and updated on July 1, 2015, when 2% chlorhexidine gluconate in 70% isopropyl alcohol replaced povidone-iodine for preoperative skin antisepsis. Protocol compliance was regularly monitored using a standardized process. No antibiotic-impregnated catheters were used.

RESULTS

A total of 621 consecutive VP shunt insertions and revisions were included in the study. The rate of shunt infection was 5.8% during the period in which there was no standardized shunt protocol. After the implementation of the CASIPP the infection rate decreased to 4.0%, and after introduction of the chlorhexidine/alcohol skin antisepsis, the infection rate was 0% in 379 consecutive procedures (p < 0.0001). Multivariable logistic regression analysis demonstrated that the use of chlorhexidine/alcohol with CASIPP was associated with a significant reduction in the odds of developing a shunt infection (OR 0.032, 95% CI 0–0.19, p = 0.0005).

CONCLUSIONS

The implementation of a standardized shunt infection prevention bundle within the adult population, without the use of antibiotic-impregnated catheters, significantly reduced the rate of shunt infections which was sustained over many years. The use of 2% chlorhexidine gluconate in 70% isopropyl alcohol for preoperative antisepsis may have played a significant role. Multicenter studies should be completed to verify the effectiveness of the authors’ protocol.

Free access

Daniel M. Bruening, Peter Truckenmueller, Christian Stein, Josch Fuellhase, Peter Vajkoczy, Thomas Picht, and Gueliz Acker

OBJECTIVE

Training of residents is an essential but time-consuming and costly task in the surgical disciplines. During the coronavirus disease 2019 pandemic, surgical education became even more challenging because of the reduced caseload due to the increased shift to corona care. In this context, augmented 360° 3D virtual reality (VR) videos of surgical procedures enable effective off-site training through virtual participation in the surgery. The goal of this study was to establish and evaluate 360° 3D VR operative videos for neurosurgical training.

METHODS

Using a 360° camera, the authors recorded three standard neurosurgical procedures: a lumbar discectomy, brain metastasis resection, and clipping of an aneurysm. Combined with the stereoscopic view of the surgical microscope, 7- to 10-minute 360° 3D VR videos augmented with annotations, overlays, and commentary were created. These videos were then presented to the neurosurgical residents at the authors’ institution using a head-mounted display. Before viewing the videos, the residents were asked to fill out a questionnaire indicating their VR experience and self-assessment of surgical skills regarding the specific procedure. After watching the videos, the residents completed another questionnaire to evaluate their quality and usefulness. The parameters were scaled with a 5-point Likert scale.

RESULTS

Twenty-two residents participated in this study. The mean years of experience of the participants in neurosurgery was 3.2 years, ranging from the 1st through the 7th year of training. Most participants (86.4%) had no or less than 15 minutes of VR experience. The overall quality of the videos was rated good to very good. Immersion, the feeling of being in the operating room, was high, and almost all participants (91%) stated that 360° VR videos provide a useful addition to the neurosurgical training. VR sickness was negligible in the cohort.

CONCLUSIONS

In this study, the authors demonstrated the feasibility and high acceptance of augmented 360° 3D VR videos in neurosurgical training. Augmentation of 360° videos with complementary and interactive content has the potential to effectively support trainees in acquiring conceptual knowledge. Further studies are necessary to investigate the effectiveness of their use in improving surgical skills.

Free access

Michelle J. Clarke and Katrin Frimannsdottir

OBJECTIVE

Structured performance evaluations are important for the professional development and personal growth of resident learners. This process is formalized by the Accreditation Council for Graduate Medical Education milestones assessment system. The primary aim of this study was to understand the current feedback delivery mechanism by exploring the culture of feedback, the mechanics of delivery, and the evaluation of the feedback itself.

METHODS

Face-to-face interviews were conducted with 10 neurosurgery residents exploring their perceptions of summative feedback. Coded data were analyzed qualitatively for overriding themes using the matrix framework method. A priori themes of definition of feedback, feedback delivery, and impact of feedback were combined with de novo themes discovered during analysis.

RESULTS

Trainees prioritized formative over summative feedback. Summative and milestone feedback were criticized as being vague, misaligned with practice, and often perceived as erroneous. Barriers to implementation of summative feedback included perceived veracity of feedback, high interrater variability, and the inconstant adoption of a developmental progression model. Gender bias was noted in degree of feedback provided and language used.

CONCLUSIONS

Trainee perception of feedback provided multiple areas of improvement. This paper can serve as a baseline to study improvements in the milestone feedback process and optimize learning.

Open access

Debajyoti Datta and Arunkumar Sekar

BACKGROUND

Eisenmenger syndrome caused by severe pulmonary arterial hypertension in congenital heart disease can cause multisystemic involvement and is a risk factor for development of cerebral abscess. Cerebral abscess, if not detected and treated in a timely manner, can present as acute neurosurgical emergency.

OBSERVATIONS

The authors reported a case of cerebral abscess in a patient with Eisenmenger syndrome. The patient presented with acute neurological deterioration with mass effect and cerebral infarcts and received emergency neurosurgical intervention. A further literature search was done to identify prior reported cases of cerebral abscess with Eisenmenger syndrome.

LESSONS

Patients with Eisenmenger syndrome have compromised cardiorespiratory status, and decision for neurosurgical intervention should be given careful consideration. Multidisciplinary team management along with preoperative optimization of the patient should be used.

Free access

Elayna P. Kirsch, Alexander Suarez, Katherine E. McDaniel, Rajeev Dharmapurikar, Timothy Dunn, Shivanand P. Lad, and Michael M. Haglund

OBJECTIVE

There is no standard way in which physicians teach or evaluate surgical residents intraoperatively, and residents are proving to not be fully competent at core surgical procedures upon graduating. The Surgical Autonomy Program (SAP) is a novel educational model that combines a modified version of the Zwisch scale with Vygotsky’s social learning theory. The objective of this study was to establish preliminary validity evidence that SAP is a reliable measure of autonomy and a useful tool for tracking competency over time.

METHODS

The SAP breaks each surgical case into 4 parts, or zones of proximal development (ZPDs). Residents are evaluated on a 4-tier autonomy scale (TAGS scale) for each ZPD in every surgical case. Attendings were provided with a teaching session about SAP and identified appropriate ZPDs for surgical cases under their area of expertise. All neurosurgery residents at Duke University Hospital from July 2017 to July 2021 participated in this study. Chi-square tests and ordinal logistic regression were used for the analyses.

RESULTS

Between 2017 and 2021, there were 4885 cases logged by 27 residents. There were 30 attendings who evaluated residents using SAP. Faculty completed evaluations on 91% of cases. The ZPD of focus directly correlated with year of residency (postgraduate year) (χ2 = 1221.1, df = 15, p < 0.001). The autonomy level increased with year of residency (χ2 = 3553.5, df = 15, p < 0.001). An ordinal regression analysis showed that for every year increase in postgraduate year, the odds of operating at a higher level of independence was 2.16 times greater (95% CI 2.11–2.21, p < 0.001). The odds of residents performing with greater autonomy was lowest for the most complex portion of the case (ZPD3) (OR 0.18, 95% CI 0.17–0.20, p < 0.001). Residents have less autonomy with increased case complexity (χ2 = 160.28, df = 6, p < 0.001). Compared with average cases, residents were more likely to operate with greater autonomy on easy cases (OR 1.44, 95% CI 1.29–1.61, p < 0.001) and less likely to do so on difficult cases (OR 0.72, 95% CI 0.67–0.77, p < 0.001).

CONCLUSIONS

This study demonstrates preliminary evidence supporting the construct validity of the SAP. This tool successfully tracks resident autonomy and progress over time. The authors’ smartphone application was widely used among surgical faculty and residents, supporting integration into the perioperative workflow. Wide implementation of SAP across multiple surgical centers will aid in the movement toward a competency-based residency education system.

Free access

Sarah Nguyen, Kyril L. Cole, Kathleen H. Timme, and Randy L. Jensen

Neurosurgery residents spend a significant amount of their time teaching patients, families, students, residents, and other health professionals. To help ensure competence in their residents’ teaching abilities, many specialties have established formal residents-as-teachers (RAT) curricula; however, such formalized curricula are often lacking in neurosurgery programs. The authors’ goal was to develop and implement a formal RAT curriculum, designed with neurosurgery residents’ other responsibilities in mind, to improve residents’ formal and informal teaching abilities. Here, the authors report on the design of a formalized teaching curriculum tailored for the needs of neurosurgical residents, with a focus on deliberate practice and minimal time needed for preparation. The curriculum, designed using Kern’s 6 steps of curriculum design as a framework, comprises 5 lecture series spread over 3 years, repeated twice through a resident’s training, with each lecture series outlined with its respective topics and objectives. Opportunities for observed teaching as well as informal and formal evaluation will be provided to residents. The program will be evaluated on a yearly basis using direct and anonymized resident feedback on the RAT curriculum. Measures of program success will also include pre- and postprogram medical student and peer evaluation of residents. These data will be used for continual improvement of the curriculum as it is implemented. Successes and shortcomings of this program will be disseminated by publication, presentations, and placement on the authors’ department website and social media. This paper may serve as a foundation for other neurosurgical programs to develop RAT curricula for greater enhancement of resident teaching abilities.

Open access

Hirohisa Yajima, Satoru Miyawaki, Satoshi Koizumi, Satoshi Kiyofuji, Hiroki Hongo, Masafumi Segawa, Taichi Kin, Hirofumi Nakatomi, and Nobuhito Saito

BACKGROUND

The precise etiology of dural arteriovenous fistula (DAVF) is still unknown. The authors reported a case of delayed postoperative sigmoid sinus (SS) DAVF secondary to SS thrombosis after resection of a foramen magnum meningioma through a suboccipital craniotomy.

OBSERVATIONS

The authors visualized the clear architecture of the DAVF using fusion three-dimensional computer graphics (3DCG) images reconstructed from multimodal imaging studies. These fusion 3DCG images revealed that the feeders of the DAVF had connected through neovascularization to the SS at the previous thrombus site. The authors also reviewed previously reported cases of DAVFs that developed after craniotomy.

LESSONS

This study indicated that SS stenosis and occlusion with sinus thrombosis are possible risk factors for delayed postoperative DAVF that demand special consideration.