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Richard Menger, Michael Wolf, Jai Deep Thakur, Anil Nanda and Anthony Martino

In 1961, President John F. Kennedy declared that the United States would send a man to the moon and safely bring him home before the end of the decade. Astronaut Michael Collins was one of those men. He flew to the moon on the historic flight of Apollo 11 while Neil Armstrong and Buzz Aldrin walked on its surface. However, this was not supposed to be the case.

Astronaut Collins was scheduled to fly on Apollo 8. While training, in 1968, he started developing symptoms of cervical myelopathy. He underwent evaluation at Wilford Hall Air Force Hospital in San Antonio and was noted to have a C5–6 disc herniation and posterior osteophyte on myelography. Air Force Lieutenant General (Dr.) Paul W. Myers performed an anterior cervical discectomy with placement of iliac bone graft. As a result, Astronaut James Lovell took his place on Apollo 8 flying the uncertain and daring first mission to the moon. This had a cascading effect on the rotation of astronauts, placing Michael Collins on the Apollo 11 flight that first landed men on the moon. It also placed Astronaut James Lovell in a rotation that exposed him to be the Commander of the fateful Apollo 13 flight.

Here, the authors chronicle the history of Astronaut Collins’ anterior cervical surgery and the impact of his procedure on the rotation of astronaut flight selection, and they review the pivotal historic nature of the Apollo 8 spaceflight. The authors further discuss the ongoing issue of cervical disc herniation among astronauts.

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Richard Menger, Patrick Kelly, Shanik Fernando, Michael E. Wolf and Anthony Martino

On May 5, 1961, Alan B. Shepard Jr. piloted the Freedom 7 craft into a suborbital flight to become the first American man in space. His promising astronautical career was soon scuttled by spells of dizziness and tinnitus later diagnosed as Ménière’s disease, until William F. House—considered the father of neurotology and a pioneer in surgery for vestibular schwannomas—intervened. In 1968 House implanted an endolymphatic-subarachnoid shunt, which at the time was a virtually experimental procedure. Shepard’s debilitating Ménière’s disease was cured, but not quite in time for him to pilot the doomed Apollo 13 mission; he was reassigned to Apollo 14 and as a result would step foot on the moon on February 5, 1971. This historical vignette depicts the tale of how the career trajectories of Shepard and House—two notable figures in their respective fields—fatefully intersected.

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Richard Menger, Benjamin F. Mundell, J. Will Robbins, Peter Letarte, Randy Bell and in conjunction with Council of State Neurosurgical Societies and AANS/CNS Joint Committee of Military Neurosurgeons

OBJECTIVE

Papers from 2002 to 2017 have highlighted consistent unique socioeconomic challenges and opportunities facing military neurosurgeons. Here, the authors focus on the reserve military neurosurgeon who carries the dual mission of both civilian and military responsibilities.

METHODS

Survey solicitation of current active duty and reserve military neurosurgeons was performed in conjunction with the AANS/CNS Joint Committee of Military Neurosurgeons and the Council of State Neurosurgical Societies. Demographic, qualitative, and quantitative data points were compared between reserve and active duty military neurosurgeons. Civilian neurosurgical provider data were taken from the 2016 NERVES (Neurosurgery Executives Resource Value and Education Society) Socio-Economic Survey. Economic modeling was done to forecast the impact of deployment or mobilization on the reserve neurosurgeon, neurosurgery practice, and the community.

RESULTS

Seventy-five percent (12/16) of current reserve neurosurgeons reported that they are satisfied with their military service. Reserve neurosurgeons make significant contributions to the military’s neurosurgical capabilities, with 75% (12/16) having been deployed during their career. No statistically significant demographic differences were found between those serving on active duty and those in the reserve service. However, those who served in the reserves were more likely to desire opportunities for improvement in the military workflow requirements compared with their active duty counterparts (p = 0.04); 92.9% (13/14) of current reserve neurosurgeons desired more flexible military drill programs specific to the needs of practicing physicians. The risk of reserve deployment is also borne by the practices, hospitals, and communities in which the neurosurgeon serves in civilian practice. This can result in fewer new patient encounters, decreased collections, decreased work relative value unit generation, increased operating costs per neurosurgeon, and intangible limitations on practice development. However, through modeling, the authors have illustrated that reserve physicians joining a larger group practice can significantly mitigate this risk. What remains astonishing is that 91.7% of those reserve neurosurgeons who were deployed noted the experience to be rewarding despite seeing a 20% reduction in income, on average, during the fiscal year of a 6-month deployment.

CONCLUSIONS

Reserve neurosurgeons are satisfied with their military service while making substantial contributions to the military’s neurosurgical capabilities, with the overwhelming majority of current military reservists having been deployed or mobilized during their reserve commitments. Through the authors’ modeling, the impact of deployment on the military neurosurgeon, neurosurgeon’s practice, and the local community can be significantly mitigated by a larger practice environment.

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Richard Menger, Austin Menger and Anil Nanda

OBJECTIVE

Multiple studies have illustrated that rugby headgear offers no statistically significant protection against concussions. However, there remains concern that many players believe rugby headgear in fact does prevent concussions. Further investigation was undertaken to illustrate that misconceptions about concussion prevention and rugby headgear may lead to an increase in aggressive play.

METHODS

Data were constructed by Internet survey solicitation among United States collegiate rugby players across 19 teams. Initial information given was related to club, age, experience, use of headgear, playing time, whether the rugger played football or wrestling in high school, and whether the player believed headgear prevented concussion. Data were then constructed as to whether wearing headgear would increase aggressive playing style secondary to a false sense of protection.

RESULTS

A total of 122 players responded. All players were male. The average player was 19.5 years old and had 2.7 years of experience. Twenty-three of 122 players (18.9%) wore protective headgear; 55.4% of players listed forward as their primary position. Overall, 45.8% (55/120) of players played 70–80 minutes per game, 44.6% (54/121) played football or wrestled in high school, 38.1% (45/118) believed headgear prevented concussions, and 42.2% (51/121) stated that if they were using headgear they would be more aggressive with their play in terms of running or tackling. Regression analysis illustrated that those who believed headgear prevented concussions were or would be more likely to engage in aggressive play (p = 0.001).

CONCLUSIONS

Nearly 40% of collegiate rugby players surveyed believed headgear helped to prevent concussions despite no scientific evidence that it does. This misconception about rugby headgear could increase aggressive play. Those who believed headgear prevented concussion were, on average, 4 times more likely to play with increased aggressive form than those who believed headgear did not prevent concussions (p = 0.001). This can place all players at increased risk without providing additional protection. Further investigation is warranted to determine if headgear increases the actual measured incidence of concussion among rugby players in the United States.

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Marc Manix, Piyush Kalakoti, Miriam Henry, Jai Thakur, Richard Menger, Bharat Guthikonda and Anil Nanda

Creutzfeldt-Jakob disease (CJD) is a rare neurodegenerative condition with a rapid disease course and a mortality rate of 100%. Several forms of the disease have been described, and the most common is the sporadic type. The most challenging aspect of this disease is its diagnosis—the gold standard for definitive diagnosis is considered to be histopatho-logical confirmation—but newer tests are providing means for an antemortem diagnosis in ways less invasive than brain biopsy. Imaging studies, electroencephalography, and biomarkers are used in conjunction with the clinical picture to try to make the diagnosis of CJD without brain tissue samples, and all of these are reviewed in this article. The current diagnostic criteria are limited; test sensitivity and specificity varies with the genetics of the disease as well as the clinical stage. Physicians may be unsure of all diagnostic testing available, and may order outdated tests or prematurely request a brain biopsy when the diagnostic workup is incomplete. The authors review CJD, discuss the role of brain biopsy in this patient population, provide a diagnostic pathway for the patient presenting with rapidly progressive dementia, and propose newer diagnostic criteria.

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Piyush Kalakoti, Symeon Missios, Richard Menger, Sunil Kukreja, Subhas Konar and Anil Nanda

OBJECT

Because of the limited data available regarding the associations between risk factors and the effect of hospital case volume on outcomes after resection of intradural spine tumors, the authors attempted to identify these associations by using a large population-based database.

METHODS

Using the National Inpatient Sample database, the authors performed a retrospective cohort study that involved patients who underwent surgery for an intradural spinal tumor between 2002 and 2011. Using national estimates, they identified associations of patient demographics, medical comorbidities, and hospital characteristics with inpatient postoperative outcomes. In addition, the effect of hospital volume on unfavorable outcomes was investigated. Hospitals that performed fewer than 14 resections in adult patients with an intradural spine tumor between 2002 and 2011 were labeled as low-volume centers, whereas those that performed 14 or more operations in that period were classified as high-volume centers (HVCs). These cutoffs were based on the median number of resections performed by hospitals registered in the National Inpatient Sample during the study period.

RESULTS

Overall, 18,297 patients across 774 hospitals in the United States underwent surgery for an intradural spine tumor. The mean age of the cohort was 56.53 ± 16.28 years, and 63% were female. The inpatient postoperative risks included mortality (0.3%), discharge to rehabilitation (28.8%), prolonged length of stay (> 75th percentile) (20.0%), high-end hospital charges (> 75th percentile) (24.9%), wound complications (1.2%), cardiac complications (0.6%), deep vein thrombosis (1.4%), pulmonary embolism (2.1%), and neurological complications, including durai tears (2.4%). Undergoing surgery at an HVC was significantly associated with a decreased chance of inpatient mortality (OR 0.39; 95% CI 0.16−0.98), unfavorable discharge (OR 0.86; 95% CI 0.76−0.98), prolonged length of stay (OR 0.69; 95% CI 0.62−0.77), high-end hospital charges (OR 0.67; 95% CI 0.60−0.74), neurological complications (OR 0.34; 95% CI 0.26−0.44), deep vein thrombosis (OR 0.65; 95% CI 0.45−0.94), wound complications (OR 0.59; 95% CI 0.41−0.86), and gastrointestinal complications (OR 0.65; 95% CI 0.46−0.92).

CONCLUSIONS

The results of this study provide individualized estimates of the risks of postoperative complications based on patient demographics and comorbidities and hospital characteristics and shows a decreased risk for most unfavorable outcomes for those who underwent surgery at an HVC. These findings could be used as a tool for risk stratification, directing presurgical evaluation, assisting with surgical decision making, and strengthening referral systems for complex cases.