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Beyond medical knowledge: a didactic curriculum focused on knowledge, wisdom, and application

Katherine E. McDaniel, Alexander Suarez, Dana G. Rowe, Brandon Bishop, Joshua Jackson, Alankrita Raghavan, Caroline Folz, Stephen Harward, Brandon Smith, Steven Cook, and C. Rory Goodwin

OBJECTIVE

The aim of this study was to determine whether a flipped classroom curriculum coupled with case-based learning would improve residents’ perceptions of the learning environment, improve education outcomes, and increase faculty engagement. Research suggests that active learning yields better educational results compared with passive learning. However, faculty are more comfortable providing lectures that require only passive participation from learners.

METHODS

A council was created to identify issues with the current format of the resident didactic curriculum and to redesign the neurosurgical curriculum and conference per Accreditation Council for Graduate Medical Education (ACGME) requirements. Trends from the authors’ 2022 and 2023 ACGME Resident Surveys were tracked to assess changes in the organizational learning environment. Surveys of resident participants were conducted to assess learner satisfaction.

RESULTS

Between July 2022 and June 2023, the authors gathered 127 survey responses from neurosurgical residents. The majority of respondents, comprising 50.4% (n = 64), were postgraduate year (PGY)–4 and PGY-5 residents. Sixty-six percent (n = 84) reported that the new format ranked within the top third of sessions they had experienced. On analysis of trends from these 2022 and 2023 ACGME Resident Surveys, the authors observed a positive trajectory in various key components. Notably, there was an upward trend in achieving an appropriate balance between service and education, in the availability of protected time for structured learning, faculty engagement and interest in education, and amount of clinical and didactic teaching.

CONCLUSIONS

The results of this study suggest that this innovative educational model can have a positive impact on residents’ perceptions of the learning environment, their educational outcomes, and faculty engagement. As residency education continues to evolve, the flipped classroom model offers an exciting avenue for enhancing the quality of residency education.

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Bilateral spheno-orbital meningiomas: surgical management, progression, and recurrence

Alexia Planty-Bonjour, Louis-Marie Terrier, Gabrielle Cognacq, Mourad Aggad, Florian Bernard, Camille Lopez, Gaston Tabourel, Guillaume Dannhoff, Frederic Bako, Gaëlle Kerdiles, Patrick Francois, and Aymeric Amelot

OBJECTIVE

Bilateral spheno-orbital meningiomas (bSOMs) are a rare entity among meningiomas. These tumors are benign and predominantly affect women. They represent 4% of spheno-orbital meningiomas (SOMs) and are poorly described in the literature. This study aimed to describe the characteristics, risk factors, evolution, and management of bSOMs.

METHODS

Twenty patients with bSOMs were enrolled in a multicentric descriptive study including 15 neurosurgical departments.

RESULTS

In this study, the authors found that bSOMs affected exclusively women, with a mean age of 50 years. Approximately 65% of patients were on progestin therapy. The mean follow-up in this series was 55 months. Clinically, visual symptoms were predominant: proptosis was present in 17 of 20 patients (85%; 7 unilateral, 10 bilateral), and a decrease in visual acuity was observed in 11 of 20 patients (55%; 6/10 to 9/10 in 6 patients, 3/10 to 5/10 in 1 patient, and < 3/10 in 4 patients). Contrary to unilateral SOMs, the authors identified that intracranial hypertension was a common presentation (25%) of bSOMs. Surgical management with gross-total resection was the gold standard treatment. Recurrences only occurred following subtotal resection in 36% to 60% of patients, with a median time of 50 to 54 months after surgery. Visual improvement or stability was observed in 75% of cases postoperatively. Progesterone receptor expression levels were 70% to 100% in 10 of 11 (91%) cases.

CONCLUSIONS

Bilateral SOMs are usually found in female patients and are strongly associated with hormone replacement therapy. Early surgical management with gross-total resection is the most effective treatment in terms of recurrence and improves visual acuity. Given the slow progressive nature of bSOMs and their time to recurrence, which can be up to 10 years, long-term follow-up of patients is essential.

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Comparing posterior cervical foraminotomy with anterior cervical discectomy and fusion in radiculopathic patients: an analysis from the Quality Outcomes Database

Praveen V. Mummaneni, Erica F. Bisson, Giorgos Michalopoulos, William J. Mualem, Sally El Sammak, Michael Y. Wang, Andrew K. Chan, Regis W. Haid, John J. Knightly, Dean Chou, Brandon A. Sherrod, Oren N. Gottfried, Christopher I. Shaffrey, Jacob L. Goldberg, Michael S. Virk, Ibrahim Hussain, Nitin Agarwal, Steven D. Glassman, Mark E. Shaffrey, Paul Park, Kevin T. Foley, Brenton Pennicooke, Domagoj Coric, Jonathan R. Slotkin, Eric A. Potts, Kai-Ming G. Fu, Anthony L. Asher, and Mohamad Bydon

OBJECTIVE

The objective of this study was to compare clinical and patient-reported outcomes (PROs) between posterior foraminotomy and anterior cervical discectomy and fusion (ACDF) in patients presenting with cervical radiculopathy.

METHODS

The Quality Outcomes Database was queried for patients who had undergone ACDF or posterior foraminotomy for radiculopathy. To create two highly homogeneous groups, optimal individual matching was performed at a 5:1 ratio between the two groups on 29 baseline variables (including demographic characteristics, comorbidities, symptoms, patient-reported scores, underlying pathologies, and levels treated). Outcomes of interest were length of stay, reoperations, patient-reported satisfaction, increase in EQ-5D score, and decrease in Neck Disability Index (NDI) scores for arm and neck pain as long as 1 year after surgery. Noninferiority analysis of achieving patient satisfaction and minimal clinically important difference (MCID) in PROs was performed with an accepted risk difference of 5%.

RESULTS

A total of 7805 eligible patients were identified: 216 of these underwent posterior foraminotomy and were matched to 1080 patients who underwent ACDF. The patients who underwent ACDF had more underlying pathologies, lower EQ-5D scores, and higher NDI and neck pain scores at baseline. Posterior foraminotomy was associated with shorter hospitalization (0.5 vs 0.9 days, p < 0.001). Reoperations within 12 months were significantly more common among the posterior foraminotomy group (4.2% vs 1.9%, p = 0.04). The two groups performed similarly in PROs, with posterior foraminotomy being noninferior to ACDF in achieving MCID in EQ-5D and neck pain scores but also having lower rates of maximal satisfaction at 12 months (North American Spine Society score of 1 achieved by 65.2% posterior foraminotomy patients vs 74.6% of ACDF patients, p = 0.02).

CONCLUSIONS

The two procedures were found to be offered to different populations, with ACDF being selected for patients with more complicated pathologies and symptoms. After individual matching, posterior foraminotomy was associated with a higher reoperation risk within 1 year after surgery compared to ACDF (4.2% vs 1.9%). In terms of 12-month PROs, posterior foraminotomy was noninferior to ACDF in improving quality of life and neck pain. The two procedures also performed similarly in improving NDI scores and arm pain, but ACDF patients had higher maximal satisfaction rates.

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Improvement of diffusion tensor imaging–based tractography by free-water correction in nonedematous gliomas: assessment with brain mapping

Fabien Almairac, Drew Parker, Lydiane Mondot, Petru Isan, Marie Onno, Théodore Papadopoulo, Denys Fontaine, and Ragini Verma

OBJECTIVE

The free-water correction algorithm (Freewater Estimator Using Interpolated Initialization [FERNET]) can be applied to standard diffusion tensor imaging (DTI) tractography to improve visualization of subcortical bundles in the peritumoral area of highly edematous brain tumors. Interest in its use for presurgical planning in purely infiltrative gliomas without peritumoral edema has never been evaluated. Using subcortical maps obtained with direct electrostimulation (DES) in awake surgery as a reference standard, the authors sought to 1) assess the accuracy of preoperative DTI-based tractography with FERNET in a series of nonedematous glioma patients, and 2) determine its potential usefulness in presurgical planning.

METHODS

Based on DES-induced functional disturbances and tumor topography, the authors retrospectively reconstructed the putatively stimulated bundles and the peritumoral tracts of interest (various associative and projection pathways) of 12 patients. The tractography data obtained with and without FERNET were compared.

RESULTS

The authors identified 21 putative tracts from 24 stimulation sites and reconstituted 49 tracts of interest. The number of streamlines of the putative tracts crossing the DES area was 26.8% higher (96.04 vs 75.75, p = 0.016) and their volume 20.4% higher (13.99 cm3 vs 11.62 cm3, p < 0.0001) with FERNET than with standard DTI. Additionally, the volume of the tracts of interest was 22.1% higher (9.69 cm3 vs 7.93 cm3, p < 0.0001).

CONCLUSIONS

Free-water correction significantly increased the anatomical plausibility of the stimulated fascicles and the volume of tracts of interest in the peritumoral area of purely infiltrative nonedematous gliomas. Because of the functional importance of the peritumoral zone, applying FERNET to DTI could have potential implications on surgical planning and the safety of glioma resection.

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Industry payments to academic neurosurgeons in 2021: an open payments cross-sectional analysis

Luca H. Debs, Seena Mansouri, W. Luke Ledford, William Woodall, and Fernando L. Vale

OBJECTIVE

The Open Payments Program (OPP) was a database started in 2013 by the US government to report payments made by the medical device and pharmaceutical industry to physicians. Neurosurgery is a technologically advanced field that relies heavily on the latest innovations for complex treatment of its patient population. This study sought to explore the financial relationship between academic neurosurgeons and the industry.

METHODS

OPP data were reviewed for the year 2021 of all faculty neurosurgeons affiliated with a neurosurgery residency program. Trends related to general payments, research payments, associated research funding, ownership and investment interest, name of the companies making payments, monetary amount of payments per company, and number of payments per company were analyzed.

RESULTS

Industry payments to 1151 US academic neurosurgeons were reviewed. These neurosurgeons received $121.4 million in payments. Three hundred thirty-two companies made 18,466 payments. The average payment per neurosurgeon was approximately six-fold higher than that of all other physicians. Vascular and spine subspecialties received the highest payments. A higher proportion of research money was allocated to the Pacific division, while all other categories (including total amount) were higher in the Eastern US. Most financial contributions were made by a small number of companies.

CONCLUSIONS

Neurosurgery has been rated by many as a field fueled by research, innovation, and technology. In 2021, academic neurosurgeons had a strong relationship with the medical device and pharmaceutical industry as reflected in the OPP data. While the true impact on patient care cannot be directly measured, the advancement of the field relies heavily on these collaborations.

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An intraoperative accelerometry and real-time analysis tool for magnetic resonance–guided focused ultrasound thalamotomy

Catherine A. Swytink-Binnema, Alan Coreas, Samuel Pichardo, G. Bruce Pike, and Zelma H. T. Kiss

Magnetic resonance–guided focused ultrasound (MRgFUS) is one of the newest surgical treatments for essential tremor (ET). During this procedure, a lesion is created within the thalamus to mitigate tremor. Targeting is done using a combination of stereotaxy, MR tractography, and sublesional heating, with tremor assessed during the procedure to gauge therapeutic effectiveness. Currently, tremor assessments are done qualitatively, but this approach requires the tremor change to be above a subjective threshold and provides no objective record of surgical tremor progression. Here, the authors present and demonstrate an MR-compatible accelerometer with custom MATLAB analysis code and graphical user interface to record, visualize, and quantify tremor in near real-time. Results can be exported and saved for future review. This method was used in 20 surgeries, with patients experiencing a 50.7% (95% CI −64.1% to −37.3%) improvement in the treated limb per the Clinical Rating Scale for Tremor. This method does not interrupt the surgery and is quantitative. As research on optimizing MRgFUS treatment for ET continues—for example, the refinement of targeting during sublesional sonications—such quantifying and recording of tremor changes will provide rapid and objective feedback.

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Letter to the Editor. New insights of MRgLITT: a first-line treatment?

Maria Sole Venanzi, Domenico Tortora, Gianluca Piatelli, and Alessandro Consales

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Letter to the Editor. Spheno-orbital meningioma

Abbass Amirjamshidi and Kazem Abbasioun

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Management of moyamoya disease: a review of current and future therapeutic strategies

Ari D. Kappel, Abdullah H. Feroze, Erickson Torio, Madhav Sukumaran, and Rose Du

Moyamoya disease (MMD) is characterized by idiopathic, progressive stenosis of the circle of Willis and the terminal portion of the internal carotid arteries with the development of prominent small collateral vessels and a characteristic moyamoya or puff-of-smoke radiographic appearance. The incidence and prevalence of MMD varies by region, age, and sex, with higher rates in Asian and East Asian populations compared to North American or European populations. There is a bimodal distribution of patients diagnosed with MMD. Pediatric patients are more commonly diagnosed within the 1st decade of life, whereas adult patients present in the 5th or 6th decade of life. Overall, there is a nearly 2:1 female-to-male ratio. Ischemic symptoms are the most common presentation in pediatric and adult populations, but adult patients are nearly twice as likely to present with intracranial hemorrhage compared to their pediatric counterparts. Surgical revascularization is indicated in symptomatic cases, and antiplatelet therapy may be a useful adjunct to prevent recurrent symptoms. Direct and combined bypass procedures seem to be more effective in adults, whereas children respond well to indirect bypass. The identification of key genetic, molecular, and environmental factors including RNF213 and GUCY1A3 loss-of-function mutations, angiogenic growth factors, autoantibodies, CNS infections, and radiation exposure suggest multiple pathways for the development of moyamoya arteriopathy. Further research is needed to better understand the heterogeneity of pathogenetic mechanisms that lead to moyamoya and to identify novel therapeutic targets to prevent, stabilize, and treat MMD.

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Objective assessment of postural ergonomics in neurosurgery: integrating wearable technology in the operating room

Alejandro Zulbaran-Rojas, Mohammad D. Rouzi, Mohsen Zahiri, Abderrahman Ouattas, Christina M. Walter, Hung Nguyen, Sanam Bidadi, Bijan Najafi, and G. Michael Lemole Jr.

OBJECTIVE

Physical stress associated with the static posture of neurosurgeons over prolonged periods can result in fatigue and musculoskeletal disorders. Objective assessment of surgical ergonomics may contribute to postural awareness and prevent further complications. This pilot study examined the feasibility of using wearable technology as a biofeedback tool to address this gap.

METHODS

Ten neurosurgeons, including 5 attendings (all faculty) and 5 trainees (1 fellow, 4 residents), were recruited and equipped with two wearable sensors attached to the back of their head and their upper back. The sensors collected the average time spent in extended (≤ −10°), neutral (> −10° and < 10°), and flexed (≥ 10°) static postures (undetected activity for more than 10 seconds) during spine and cranial procedures. Feasibility outcomes aimed for more than 70% of accurate data collection. Exploratory outcomes included the comparison of postural variability within and between participants adjusted to their demographics excluding nonrelated surgical activities, and postoperative self-assessment surveys.

RESULTS

Sixteen (80%) of 20 possible recordings were successfully collected and analyzed from 11 procedures (8 spine, 3 cranial). Surgeons maintained a static posture during 52.7% of the active surgical time (mean 1.58 hrs). During spine procedures, all surgeons used an exoscope while standing, leading to a significantly longer time spent in a neutral static posture (p < 0.001, partial η2 = 0.14): attendings remained longer in a neutral static posture (36.4% ± 15.3%) than in the extended (9% ± 6.3%) and flexed (5.7% ± 3.4%) static postures; trainees also remained longer in a neutral static posture (30.2% ± 13.8%) than in the extended (11.1% ± 6.3%) and flexed (11.9% ± 6.6%) static postures. During cranial procedures, surgeons intermittently transitioned between standing/exoscope use and sitting/microscope use, with trainees spending a shorter time in a neutral static posture (16.3% vs 48.5%, p < 0.001) and a longer time in a flexed static posture (18.5% vs 2.7%, p < 0.001) compared with attendings. Additionally, longer cranial procedures correlated with surgeons spending a longer time (r = 0.94) in any static posture (extended, flexed, and neutral), with taller surgeons exhibiting longer periods in flexed and extended static postures (r = 0.86). Postoperative self-assessment revealed that attendings perceived spine procedures as more difficult than trainees (p = 0.029), while trainees found cranial procedures to be of greater difficulty than spine procedures (p = 0.012). Attendings felt more stressed (p = 0.048), less calmed (p = 0.024), less relaxed (p = 0.048), and experienced greater stiffness in their upper body (p = 0.048) and more shoulder pain (p = 0.024) during cranial versus spine procedures.

CONCLUSIONS

Wearable technology is feasible to assess postural ergonomics and provide objective biofeedback to neurosurgeons during spine and cranial procedures. This study showed reproducibility for future comparative protocols focused on correcting posture and surgical ergonomic education.