Daniel Lubelski, Roy Xiao, Debraj Mukherjee, William W. Ashley, Timothy Witham, Henry Brem, Judy Huang and Stacey Quintero Wolfe
Neurosurgery seeks to attract the best and brightest medical students; however, there is often a lack of early exposure to the field, among other possible barriers. The authors sought to identify successful practices that can be implemented to improve medical student recruitment to neurosurgery.
United States neurosurgery residency program directors were surveyed to determine the number of medical student rotators and medical students matching into a neurosurgery residency from their programs between 2010 and 2016. Program directors were asked about the ways their respective institutions integrated medical students into departmental clinical and research activities.
Complete responses were received from 30/110 institutions. Fifty-two percent of the institutions had neurosurgery didactic lectures for 1st- and 2nd-year medical students (MS1/2), and 87% had didactics for MS3/4. Seventy-seven percent of departments had a neurosurgery interest group, which was the most common method used to integrate medical students into the department. Other forms of outreach included formal mentorship programs (53%), lecture series (57%), and neurosurgery anatomy labs (40%). Seventy-three percent of programs provided research opportunities to medical students, and 57% indicated that the schools had a formal research requirement. On average, 3 medical students did a rotation in each neurosurgery department and 1 matched into neurosurgery each year. However, there was substantial variability among programs. Over the 2010–2016 period, the responding institutions matched as many as 4% of the graduating class into neurosurgery per year, whereas others matched 0%–1%. Departments that matched a greater (≥ 1% per year) number of medical students into neurosurgery were significantly more likely to have a neurosurgery interest group and formal research requirements. A greater percentage of high-matching programs had neurosurgery mentorship programs, lecture series, and cadaver training opportunities compared to the other institutions.
In recent decades, the number of applicants to neurosurgery has decreased. A major deterrent may be the delayed exposure of medical students to neurosurgery. Institutions with early preclinical exposure, active neurosurgery interest groups, research opportunities, and strong mentorship recruit and match more students into neurosurgery. Implementing such initiatives on a national level may increase the number of highly qualified medical students pursuing neurosurgery.
Roy Xiao, Jacob A. Miller, Navin C. Sabharwal, Daniel Lubelski, Vincent J. Alentado, Andrew T. Healy, Thomas E. Mroz and Edward C. Benzel
Improvements in imaging technology have steadily advanced surgical approaches. Within the field of spine surgery, assistance from the O-arm Multidimensional Surgical Imaging System has been established to yield superior accuracy of pedicle screw insertion compared with freehand and fluoroscopic approaches. Despite this evidence, no studies have investigated the clinical relevance associated with increased accuracy. Accordingly, the objective of this study was to investigate the clinical outcomes following thoracolumbar spinal fusion associated with O-arm–assisted navigation. The authors hypothesized that increased accuracy achieved with O-arm–assisted navigation decreases the rate of reoperation secondary to reduced hardware failure and screw misplacement.
A consecutive retrospective review of all patients who underwent open thoracolumbar spinal fusion at a single tertiary-care institution between December 2012 and December 2014 was conducted. Outcomes assessed included operative time, length of hospital stay, and rates of readmission and reoperation. Mixed-effects Cox proportional hazards modeling, with surgeon as a random effect, was used to investigate the association between O-arm–assisted navigation and postoperative outcomes.
Among 1208 procedures, 614 were performed with O-arm–assisted navigation, 356 using freehand techniques, and 238 using fluoroscopic guidance. The most common indication for surgery was spondylolisthesis (56.2%), and most patients underwent a posterolateral fusion only (59.4%). Although O-arm procedures involved more vertebral levels compared with the combined freehand/fluoroscopy cohort (4.79 vs 4.26 vertebral levels; p < 0.01), no significant differences in operative time were observed (4.40 vs 4.30 hours; p = 0.38). Patients who underwent an O-arm procedure experienced shorter hospital stays (4.72 vs 5.43 days; p < 0.01). O-arm–assisted navigation trended toward predicting decreased risk of spine-related readmission (0.8% vs 2.2%, risk ratio [RR] 0.37; p = 0.05) and overall readmissions (4.9% vs 7.4%, RR 0.66; p = 0.07). The O-arm was significantly associated with decreased risk of reoperation for hardware failure (2.9% vs 5.9%, RR 0.50; p = 0.01), screw misplacement (1.6% vs 4.2%, RR 0.39; p < 0.01), and all-cause reoperation (5.2% vs 10.9%, RR 0.48; p < 0.01). Mixed-effects Cox proportional hazards modeling revealed that O-arm–assisted navigation was a significant predictor of decreased risk of reoperation (HR 0.49; p < 0.01). The protective effect of O-arm–assisted navigation against reoperation was durable in subset analysis of procedures involving < 5 vertebral levels (HR 0.44; p = 0.01) and ≥ 5 levels (HR 0.48; p = 0.03). Further subset analysis demonstrated that O-arm–assisted navigation predicted decreased risk of reoperation among patients undergoing posterolateral fusion only (HR 0.39; p < 0.01) and anterior lumbar interbody fusion (HR 0.22; p = 0.03), but not posterior/transforaminal lumbar interbody fusion.
To the authors' knowledge, the present study is the first to investigate clinical outcomes associated with O-arm–assisted navigation following thoracolumbar spinal fusion. O-arm–assisted navigation decreased the risk of reoperation to less than half the risk associated with freehand and fluoroscopic approaches. Future randomized controlled trials to corroborate the findings of the present study are warranted.
2010 AANS Annual Meeting Philadelphia, Pennsylvania May 1–5, 2010