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M. Harrison Snyder, Vamsi P. Reddy, Ankitha M. Iyer, Aruna Ganju, Nathan R. Selden, Jeremiah N. Johnson, Stacey Q. Wolfe, and on behalf of the Society of Neurological Surgeons and American Association of Neurological Surgeons Young Neurosurgeons Committee

OBJECTIVE

The COVID-19 pandemic caused a significant disruption to residency recruitment, including a sudden, comprehensive transition to virtual interviews. The authors sought to characterize applicant experiences and perceptions concerning the change in the application, interview, and match process for neurological surgery residency during the 2020–2021 recruitment cycle.

METHODS

A national survey of neurosurgical residency applicants from the 2020–2021 application cycle was performed. This survey was developed in cooperation with the Society of Neurological Surgeons (SNS) and the American Association of Neurological Surgeons Young Neurosurgeons Committee (YNC) and sent to all applicants (n = 280) who included academic video submissions to the SNS repository as part of their application package. These 280 applicants accounted for 69.6% of the total 402 neurosurgical applicants this year.

RESULTS

Nearly half of the applicants responded to the survey (44.3%, 124 of 280). Applicants favored additional reform of the interview scheduling process, including a centralized scheduling method, a set of standardized release dates for interview invitations, and interview caps for applicants. Less than 8% of students desired a virtual-only platform in the future, though the majority of applicants supported incorporating virtual interviews as part of the process to contain applicant costs and combining them with traditional in-person interview opportunities. Program culture and fit, as well as clinical and research opportunities in subspecialty areas, were the most important factors applicants used to rank programs. However, subjective program "fit" was deemed challenging to assess during virtual-only interviews.

CONCLUSIONS

Neurosurgery resident applicants identified standardized interview invitation release dates, centralized interview scheduling methods, caps on the number of interviews available to each candidate, and regulated opportunities for both virtual and in-person recruitment as measures that could significantly improve the applicant experience during and effectiveness of future neurosurgery residency application cycles. Applicants prioritized program culture and "fit" during recruitment, and a majority were open to incorporating virtual elements into future cycles to reduce costs while retaining in-person opportunities to gauge programs and their locations.

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Syed Hassan A. Akbari, Gabriela R. Oates, Irina Gonzalez-Sigler, Anastasia A. Arynchyna, Justin McCroskey, Elizabeth N. Alford, Tofey J. Leon, Sarah Rutland, James M. Johnston, Jeffrey P. Blount, Curtis J. Rozzelle, and Brandon G. Rocque

OBJECTIVE

There is little research on the effect of social determinants of health on Chiari malformation type I (CM-I). The authors analyzed data on all children evaluated for CM-I at a single institution to assess how socioeconomic factors and race affect the surgical treatment of this population.

METHODS

Medical records of patients treated for CM-I at the authors’ institution between 1992 and 2017 were reviewed. Area Deprivation Index (ADI) and Rural-Urban Commuting Area (RUCA) codes for each patient were used to measure neighborhood disadvantage. Non-Hispanic White patients were compared to non-White patients and Hispanic patients of any race (grouped together as non-White in this study) in terms of insurance status, ADI, and RUCA. Patients with initially benign CM-I, defined as not having undergone surgery within 9 months of their initial visit, were then stratified by having delayed symptom presentation or not, and compared on these same measures.

RESULTS

The sample included 665 patients with CM-I: 82% non-Hispanic White and 18% non-White. The non-White patients were more likely to reside in disadvantaged (OR 3.4, p < 0.001) and urban (OR 4.66, p < 0.001) neighborhoods and to have public health insurance (OR 3.11, p < 0.001). More than one-quarter (29%) of patients underwent surgery. The non-White and non-Hispanic White patients had similar surgery rates (29.5% vs 28.9%, p = 0.895) at similar ages (8.8 vs 9.7 years, p = 0.406). There were no differences by race/ethnicity for symptoms at presentation. Surgical and nonsurgical patients had similar ADI scores (3.9 vs 4.2, p = 0.194), RUCA scores (2.1 vs 2.3, p = 0.252), and private health insurance rates (73.6% vs 74.2%, p = 0.878). A total of 153 patients underwent surgery within 9 months of their initial visit. The remaining 512 were deemed to have benign CM-I. Of these, 40 (7.8%) underwent decompression surgery for delayed symptom presentation. Patients with delayed symptom presentation were from less disadvantaged (ADI 3.2 vs 4.2; p = 0.025) and less rural (RUCA 1.8 vs 2.3; p = 0.023) areas than those who never underwent surgery.

CONCLUSIONS

Although non-White patients were more likely to be socioeconomically disadvantaged, race and socioeconomic disadvantage were not associated with undergoing surgical treatment. However, among patients with benign CM-I, those undergoing decompression for delayed symptom presentation resided in more affluent and urban areas.

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Andrew M. Hersh, Zach Pennington, Bethany Hung, Jaimin Patel, Earl Goldsborough, Andrew Schilling, James Feghali, Albert Antar, Siddhartha Srivastava, David Botros, Aladine A. Elsamadicy, Sheng-Fu Larry Lo, and Daniel M. Sciubba

OBJECTIVE

Frailty—the state defined by decreased physiological reserve and increased vulnerability to physiological stress—is exceedingly common in oncology patients. Given the palliative nature of spine metastasis surgery, it is imperative that patients be healthy enough to tolerate the physical insult of surgery. In the present study, the authors compared the association of two frailty metrics and the widely used Charlson Comorbidity Index (CCI) with postoperative morbidity in spine metastasis patients.

METHODS

A retrospective cohort of patients who underwent operations for spinal metastases at a comprehensive cancer center were identified. Data on patient demographic characteristics, disease state, medical comorbidities, operative details, and postoperative outcomes were collected. Frailty was measured with the modified 5-item frailty index (mFI-5) and metastatic spinal tumor frailty index (MSTFI). Outcomes of interest were length of stay (LOS) greater than the 75th percentile of the cohort, nonroutine discharge, and the occurrence of ≥ 1 postoperative complication.

RESULTS

In total, 322 patients were included (mean age 59.5 ± 12 years; 56.9% of patients were male). The mean ± SD LOS was 11.2 ± 9.9 days, 44.5% of patients had nonroutine discharge, and 24.0% experienced ≥ 1 postoperative complication. On multivariable analysis, increased frailty on mFI-5 and MSTFI was independently predictive of all three outcomes: prolonged LOS (OR 1.67 per point, 95% CI 1.06–2.63, p = 0.03; and OR 1.63 per point, 95% CI 1.29–2.05, p < 0.01, respectively), nonroutine discharge (OR 2.65 per point, 95% CI 1.74–4.04, p < 0.01; and OR 1.69 per point, 95% CI 1.36–2.11, p < 0.01), and ≥ 1 complication (OR 1.95 per point, 95% CI 1.23–3.09, p = 0.01; and OR 1.41 per point, 95% CI 1.12–1.77, p < 0.01). CCI was found to be independently predictive of only the occurrence of ≥ 1 postoperative complication (OR 1.45 per point, 95% CI 1.22–1.72, p < 0.01).

CONCLUSIONS

Frailty measured with either mFI-5 or MSTFI scores was a more robust independent predictor of adverse postoperative outcomes than the more widely used CCI. Both mFI-5 and MSTFI were significantly associated with prolonged LOS, higher complication rates, and nonroutine discharge. Further investigation in a prospective multicenter cohort is merited.

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Omaditya Khanna, Christopher J. Farrell, Ellina Hattar, Fadi Al Saiegh, Ritam Ghosh, Thana N. Theofanis, Michelle Hoffman, and Ashwini D. Sharan

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Hyung Rae Lee, Dong-Ho Lee, Jae Hwan Cho, Eui Seung Hwang, Sang Yun Seok, Sehan Park, and Choon Sung Lee

OBJECTIVE

The objective of this study was to evaluate the feasibility and complications of the over-the-arch (OTA) technique for screw insertion into the C1 lateral mass in patients in whom conventional techniques (i.e., posterior arch [PA] and inferior lateral mass [ILM]) are not feasible due to 1) PA with a very small height (< 3.5 mm), 2) a caudally tilted PA blocking the inferior part of the C1 lateral mass, or 3) loss of height at the ILM (< 3.5 mm).

METHODS

The authors reviewed the medical records of 60 patients who underwent C1 screw fixation with the OTA technique (13 screws) and the PA/ILM technique (107 screws) between 2011 and 2019. Vertebral artery (VA) injuries, screw malposition, and bony union were radiologically assessed. Clinical outcome measures, including Neck Disability Index (NDI), Japanese Orthopaedic Association (JOA) scale score, and occipital neuralgia, were recorded.

RESULTS

Thirteen OTA screws were successfully inserted without any major complications. NDI and JOA scale scores did not show significant differences between the two groups at final follow-up. No VA injuries were recognized during screw insertion. There was no evidence of ischemic damage to the VA or bony erosion in the occiput or atlas. Medial wall violation was observed in 1 screw (7.7%); however, no C0–1, C1–2, or lateral wall violations were observed. No patients developed new-onset neuralgia postoperatively after C1 fixation with the OTA technique.

CONCLUSIONS

The OTA technique was safe and useful for C1 screw fixation in patients in whom conventional techniques could not be employed.

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Hisanori Ikuma, Tomohiko Hirose, Shinichiro Takao, Masataka Ueda, Kazutaka Yamashita, Kazutoshi Otsuka, and Keisuke Kawasaki

OBJECTIVE

Patients with ankylosing spinal disorders (ASDs), such as ankylosing spondylitis and diffuse idiopathic skeletal hyperostosis, often have rigid kyphosis of the spine. The fracture site is sometimes unintentionally displaced when surgery is conducted with the patient prone. To prevent this incident, the authors adopted the lateral decubitus position for patients intraoperatively for this pathology. The aim of this study was to retrospectively assess the impact of the lateral decubitus position in the perioperative period on posterior fixation for thoracolumbar fractures with ASD.

METHODS

Thirty-seven consecutive patients who underwent posterior instrumentation for thoracolumbar fracture with ASD at the authors’ institute were divided into 15 lateral decubitus positions (group L) and 22 prone positions (group P). Surgical time, estimated blood loss (EBL), number of levels fused, perioperative complications, length of stay (LOS), ratio of fracture voids, and ratio of anterior wall height were investigated. The ratio of fracture void and the ratio of anterior wall height were the radiological assessments showing a degree of reduction in vertebral fracture on CT.

RESULTS

Age, sex, BMI, fracture level, and LOS were similar between the groups. Levels fused and EBL were significantly shorter and less in group L (p < 0.001 and p = 0.04), but there was no significant difference in surgical time. The complication rate was similar, but 1 death within 90 days after surgery was found in group P. The ratio of fracture voids was 85.4% ± 12.8% for group L and 117.5% ± 37.3% for group P. A significantly larger number of patients with a fracture void ratio of 100% or less was found in group L (86.7% vs 36.4%, p = 0.002). The ratio of anterior wall height was 107.5% ± 12.3% for group L and 116.9% ± 18.8% for group P. A significantly larger number of patients with the anterior wall height ratio of 100% or less was also found in group L (60.0% vs 27.3%, p = 0.046).

CONCLUSIONS

The results of this study suggest that the lateral decubitus position can be expected to have an effect on closing or maintaining the fracture void or a preventive effect of intraoperative unintentional extension displacement of the fractured site, which is often seen in the prone position during surgery for thoracolumbar fractures involving ASD.

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Hao You, Xing Fan, Jiajia Liu, Dongze Guo, Zhibao Li, and Hui Qiao

OBJECTIVE

The current study investigated the correlation between intraoperative motor evoked potential (MEP) and somatosensory evoked potential (SSEP) monitoring and both short-term and long-term motor outcomes in aneurysm patients treated with surgical clipping. Moreover, the authors provide a relatively optimal neurophysiological predictor of postoperative motor deficits (PMDs) in patients with ruptured and unruptured aneurysms.

METHODS

A total of 1017 patients (216 with ruptured aneurysms and 801 with unruptured aneurysms) were included. Patient demographic characteristics, clinical features, intraoperative monitoring data, and follow-up data were retrospectively reviewed. The efficacy of using changes in MEP/SSEP to predict PMDs was assessed using binary logistic regression analysis. Subsequently, receiver operating characteristic curve analysis was performed to determine the optimal critical value for duration of MEP/SSEP deterioration.

RESULTS

Both intraoperative MEP and SSEP monitoring were significantly effective for predicting short-term (p < 0.001 for both) and long-term (p < 0.001 for both) PMDs in aneurysm patients. The critical values for predicting short-term PMDs were amplitude decrease rates of 57.30% for MEP (p < 0.001 and area under the curve [AUC] 0.732) and 64.10% for SSEP (p < 0.001 and AUC 0.653). In patients with an unruptured aneurysm, the optimal critical values for predicting short-term PMDs were durations of deterioration of 17 minutes for MEP (p < 0.001 and AUC 0.768) and 21 minutes for SSEP (p < 0.001 and AUC 0.843). In patients with a ruptured aneurysm, the optimal critical values for predicting short-term PMDs were durations of deterioration of 12.5 minutes for MEP (p = 0.028 and AUC 0.706) and 11 minutes for SSEP (p = 0.043 and AUC 0.813).

CONCLUSIONS

The authors found that both intraoperative MEP and SSEP monitoring are useful for predicting short-term and long-term PMDs in patients with unruptured and ruptured aneurysms. The optimal intraoperative neuromonitoring method for predicting PMDs varies depending on whether the aneurysm has ruptured or not.

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Jenny C. Kienzler, Stephen Tenn, Srinivas Chivukula, Fang-I Chu, Hiro D. Sparks, Nzhde Agazaryan, Won Kim, Antonio De Salles, Michael Selch, Alessandra Gorgulho, Tania Kaprealian, and Nader Pouratian

OBJECTIVE

Precise and accurate targeting is critical to optimize outcomes after stereotactic radiosurgery (SRS) for trigeminal neuralgia (TN). The aim of this study was to compare the outcomes after SRS for TN in which two different techniques were used: mask-based 4-mm cone versus frame-based 5-mm cone.

METHODS

The authors performed a retrospective review of patients who underwent SRS for TN at their institution between 1996 and 2019. The Barrow Neurological Institute (BNI) pain score and facial hypesthesia scale were used to evaluate pain relief and facial numbness.

RESULTS

A total of 234 patients were included in this study; the mean age was 67 years. In 97 patients (41.5%) radiation was collimated by a mask-based 4-mm cone, whereas a frame-based 5-mm cone was used in the remaining 137 patients (58.5%). The initial adequate pain control rate (BNI I–III) was 93.4% in the frame-based 5-mm group, compared to 87.6% in the mask-based 4-mm group. This difference between groups lasted, with an adequate pain control rate at ≥ 24 months of 89.9% and 77.8%, respectively. Pain relief was significantly different between groups from initial response until the last follow-up (≥ 24 months, p = 0.02). A new, permanent facial hypesthesia occurred in 30.3% of patients (33.6% in the frame-based 5-mm group vs 25.8% in the mask-based 4-mm group). However, no significant association between the BNI facial hypesthesia score and groups was found. Pain recurrence occurred earlier (median time to recurrence 12 months vs 29 months, p = 0.016) and more frequently (38.1% vs 20.4%, p = 0.003) in the mask-based 4-mm than in the frame-based 5-mm group.

CONCLUSIONS

Frame-based 5-mm collimator SRS for TN resulted in a better long-term pain relief with similar toxicity profiles to that seen with mask-based 4-mm collimator SRS.

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Mark D. Dijkman, Martine W. T. van Bilsen, Michael G. Fehlings, and Ronald H. M. A. Bartels

OBJECTIVE

Degenerative cervical myelopathy (DCM) is a major global cause of spinal cord dysfunction. Surgical treatment is considered a safe and effective way to improve functional outcome, although information about long-term functional outcome remains scarce despite increasing longevity. The objective of this study was to describe functional outcome 10 years after surgery for DCM.

METHODS

A prospective observational cohort study was undertaken in a university-affiliated neurosurgery department. All patients who underwent surgery for DCM between 2008 and 2010 as part of the multicenter Cervical Spondylotic Myelopathy International trial were included. Participants were approached for additional virtual assessment 10 years after surgery. Functional outcome was assessed according to the modified Japanese Orthopaedic Association (mJOA; scores 0–18) score at baseline and 1, 2, and 10 years after surgery. The minimal clinically important difference was defined as 1-, 2-, or 3-point improvement for mild, moderate, and severe myelopathy, respectively. Outcome was considered durable when stabilization or improvement after 2 years was maintained at 10 years. Self-evaluated effect of surgery was assessed using a 4-point Likert-like scale. Demographic, clinical, and surgical data were compared between groups that worsened and improved or remained stable using descriptive statistics. Functional outcome was compared between various time points during follow-up with linear mixed models.

RESULTS

Of the 42 originally included patients, 37 participated at follow-up (11.9% loss to follow-up, 100% response rate). The mean patient age was 56.1 years, and 42.9% of patients were female. Surgical approaches were anterior (76.2%), posterior (21.4%), or posterior with fusion (2.4%). The mean follow-up was 10.8 years (range 10–12 years). The mean mJOA score increased significantly from 13.1 (SD 2.3) at baseline to 14.2 (SD 3.3) at 10 years (p = 0.01). A minimal clinically important difference was achieved in 54.1%, and stabilization of functional status was maintained in 75.0% in the long term. Patients who worsened were older (median 63 vs 52 years, p < 0.01) and had more comorbidities (70.0% vs 25.9%, p < 0.01). A beneficial effect of surgery was self-reported by 78.3% of patients.

CONCLUSIONS

Surgical treatment for DCM results in satisfactory improvement of functional outcome that is maintained at 10-year follow-up.

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MirHojjat Khorasanizadeh, Yu-Ming Chang, Alejandro Enriquez-Marulanda, Satomi Mizuhashi, Mohamed M. Salem, Santiago Gomez-Paz, Farhan Siddiq, Peter Kan, Justin Moore, Christopher S. Ogilvy, and Ajith J. Thomas

OBJECTIVE

Middle meningeal artery embolization (MMAE) is an increasingly utilized approach for the treatment of chronic subdural hematomas (CSDHs). The course of morphological progression of CSDHs following MMAE is poorly understood. Herein, the authors aimed to describe these morphological changes and assess their prognostic significance for the outcomes on follow-up.

METHODS

A single-institution retrospective cohort study of CSDH cases treated by upfront MMAE, without prior or adjunctive surgical evacuation, was performed. Clinical outcomes, complications, and the need for rescue surgery on follow-up were recorded. Hematomas were categorized into 6 morphological subtypes. All baseline and follow-up head CT scans were assessed for CSDH structural appearance, density, and loculation. Changes in CSDH size were quantified via 3D reconstruction for volumetric measurement.

RESULTS

Overall, 52 CSDHs in 45 patients treated with upfront MMAE were identified. Hematomas were followed for a mean of 92.9 days. Volume decreased by ≥ 50% in 79.6% of the CSDHs. The overall rescue surgery rate was 9.6%. A sequence of morphological changes after MMAE was identified. Hematomas that diverged from this sequence (5.4%) all progressed toward treatment failure and required rescue surgery. The CSDHs were categorized into early, intermediate, and late stages based on the baseline morphological appearance. Progression from early to intermediate and then to late stage took 12.7 and 30.0 days, respectively, on average. The volume of early/intermediate- and late-stage hematomas decreased by ≥ 50%, a mean of 78.2 and 47.6 days after MMAE, respectively. Early- and intermediate-stage hematomas showed a trend toward more favorable outcomes compared with late-stage hematomas. The density of homogeneous hypodense hematomas (HSDHs) transiently increased immediately after MMAE (p < 0.001). A marked decrease in density and volume 1 to 3 weeks after MMAE in HSDHs was detected, the lack of which indicated an eventual need for rescue surgery. In HSDHs, a baseline mean density of < 20 HU, and a lower density than baseline by 1 month post-MMAE were predictors of favorable outcomes. The baseline hematoma volume, axial thickness, midline shift, and loculation were not correlated with MMAE outcomes. Loculated, trabecular, and laminar hematomas, which are known to have unfavorable surgical outcomes, had MMAE outcomes similar to those of other "surgical" hematomas.

CONCLUSIONS

The current study was the first to describe the nature, sequence, and timing of morphological changes of CSDHs after MMAE treatment and has identified structural features that can predict treatment outcomes.