The neurosurgical curriculum: Which procedures are essential?

Objective: Traditionally, neurosurgery is a competitive field. Throughout the years, the surgical armamentarium has been subject to change, e.g. due to the rise of indications for gamma knife, functional or endovascular surgery. Furthermore, due to modern day issues among residents, such as work hour restrictions (WHRs) and prevalence of burn-out, may require contemporary modifications of the neurosurgical curriculum. By the means of this cross sectional research, the current curriculum is evaluated. Methods: In September 2019, a 21-question survey was mailed to members of the Congress of Neurological Surgeons using SurveyMonkey. The survey consisted out of 3 parts: demographics of the respondents, respondent‘s neurosurgical residency and opinions on essential procedures. Results: After the two reminders, 578 members responded resulting in a response rate of 7.3%. Respondents had a mean residency program of 7 years (range 3 to 12 years). Of the residents, 87.5% had a weekly WHR of 80 h per week. A minority (43.8%) felt WHRs would limit the chances of residents to master surgical techniques. Neurotraumatical procedures such as decompression of subdural (91.5%) and epidural (91.3%) hematoma‘s, ventriculoperitoneal shunt insertion (86.9%), Chiari decompression (81.4%) and cervical discectomy (81.4%) were the procedures respondents mastered the most. This in contrast to endovascular procedures (67.9%), percutaneous endoscopic lumbar discectomy (48.5%) and deep brain stimulation (34%), in which respondents were less proficient. Conclusions: The current study gives an evaluation of different neurosurgical curricula and aimed to identify which surgical procedures are deemed as essential by neurosurgeons worldwide. Functiona

Body Image and Cosmesis after Percutaneous Transforaminal Endoscopic Discectomy versus Conventional Open Microdiscectomy for Sciatica

Study Design: Randomized controlled trial Objective: Percutaneous transforaminal endoscopic discectomy (PTED) was introduced as a less invasive procedure to treat sciatica. Even though the PTED has a small scar size, it is unknown if PTED also leads to better scar-related patient-reported outcomes. Therefore, we aimed to compare scar-related outcomes between patients undergoing PTED vs open microdiscectomy. Methods: Patients with at least 6 weeks of radiating leg pain were randomized in a 1:1 ratio to PTED or open microdiscectomy. Scar-related patient-reported outcomes were measured using the Body Image Score (BIS), Cosmesis Scale (CS) and a 0-10 numeric rating scale (NRS) on scar esthetic. Results: Of the 530 included patients, 286 patients underwent PTED and 244 underwent open microdiscectomy as allocated. At 12 months of follow-up, 95% of the patients had data available. At 12 months, the BIS was 6.2 ± 1.7 in the PTED-group and 6.6 ± 1.9 in the open microdiscectomy group (between-group difference.4, 95% CI.2 to.7). CS was 21.3 ± 3.0 in the PTED-group and 18.6 ± 3.4 in the open microdiscectomy group (between-group difference −2.7, 95% CI −3.1 to −2.3). Average NRS for scar esthetic was 9.2 ± 1.3 and 7.8 ± 1.6 in the PTED and open microdiscectomy groups, respectively (between-group difference −1.4, 95% CI −1.6 to −1.2) Conclusions: PTED leads to a higher self-rated scar esthetic as compared to open microdiscectomy, while self-reported body image seems to be comparable between both groups. Therefore, from an esthetic point, PTED seems to be the preferred technique to treat sciatica.</p

Anterior cervical discectomy without fusion for a symptomatic cervical disk herniation

Background: Cervical radiculopathy is characterized by dysfunction of the nerve root usually caused by a cervical disk herniation. The most important symptom is pain, radiating from the neck to the arm. When conservative treatment fails, surgical treatment is indicated to relieve symptoms. During the last decades, multiple fusion techniques have been developed, although without clinical evidence for added value of fusion over non-fusion. Methods: The surgical procedure of anterior cervical discectomy without fusion is performed step by step, leading to removal of the entire intervertebral disk. Conclusion: Anterior cervical discectomy without fusion is a safe and effective treatment for cervical disk herniation

Safety Culture and Attitudes Among Spine Professionals: Results of an International Survey

Study Design: International survey. Objective: A positive safety culture has been linked to better surgical outcomes, less hospital costs and less patient harm and severity-adjusted mortality, making safety attitudes relevant for society and both patient and health care provider. The aim of the current study is to assess attitudes toward safety culture among spinal care professionals. Methods: An online survey was distributed to members of AOSpine International in 2016. The survey consisted out of 3 parts: (1) demographics, (2) the Safety Attitude Questionnaire (SAQ), and (3) expectations of responsibility for improving the safety culture. The SAQ measured job satisfaction, teamwork, and safety climate, perceptions of management, stress recognition, and working conditions. Multivariate logistic regression was performed to identify factors associated with safety attitudes. Results: A total of 356 respondents replied. The SAQ showed that respondents in Africa have a significant lower score (odds ratio [OR] 0.19, P .05). The majority expected the surgeon to be mainly responsible for improving the safety culture in the operating room and at management level. Conclusions: There was a lot of variety among different respondents worldwide albeit respondents in Africa scored significantly lower on working conditions, compared with spine professionals in Asia and North America, suggesting that wealthier countries have better working conditions which may lead toward better safety attitudes. Closer collaboration between hospital management and clinicians seems to be a target for improvement in safety culture. Furthermore, to show clinical relevance in this field, studies correlating safety attitudes with outcomes after spine surgery are warranted

Catheter Access Port (Computed Tomography) Myelography in Intrathecal Drug Delivery Troubleshooting: A Case Series of 70 Procedures

Objectives: Intrathecal drug delivery is used for the treatment of intractable spasticity, dystonia, and pain. When the symptomatology fails to respond to therapy, the cause could be failure of the medication infusion. The purpose of this study is to assess pump catheter access port (CAP)-myelography and CAP-CT-myelography as advanced imaging methods in treatment failure. Materials and Methods: We analyzed observational routinely collected data of 70 CAP procedures with 2D/3D reconstructions and additional imaging of 53 adult patients where the cause of treatment was unclear between November 2013 and November 2018. CAP-myelography and CAP-CT myelography were performed with postprocessing 2D/3D reconstructions. When myelography could not be obtained or when the result did not reveal the cause of the treatment failure, additional procedures, such as noncontrast CT, MRI, lumbar puncture CT, and 111Indium-DTPA SPECT-CT, were performed. Results: CAP fluid aspiration prior to contrast medium injection was not possible (N = 17). In one case, contrast was injected into the pump pocket unintentionally (N = 1). Of 70 procedures, 24% were unaspiratable. The remaining CAP myelography examinations (N = 52) had limited value for the diagnosis. CAP-CT myelography (N = 50) was normal (N = 31). The abnormal results (N = 19) were dorsal dural leak (N = 5), subdural catheter position (N = 2), limited rostral flow of contrast material (N = 4), limited and abnormal contrast distribution (N = 3), obstruction of rostral flow (N = 2), a leak at the pump-catheter connection (N = 1), and a sheared catheter localized in the pump pocket (N = 2). Limited contrast distributions were found to be false positive findings (N = 2). Four normal CT-CAP myelographic procedures were false negatives, as the reference tests revealed a cause of intrathecal drug delivery (ITDD) failure. The CAP-CT procedures resulted in a sensitivity of 81% (17/21) and a specificity of 93% (27/29). Conclusions: CAP-CT myelography with 2D/3D reconstructions is an essential step in the diagnostic algorithm for cases involving ITDD failure

Cytosolic enzymes with a mitochondrial ancestry from the anaerobic chytrid Piromyces sp. E2

The anaerobic chytrid Piromyces sp. E2 lacks mitochondria, but contains hydrogen-producing organelles, the hydrogenosomes. We are interested in how the adaptation to anaerobiosis influenced enzyme compartmentalization in this organism. Random sequencing of a cDNA library from Piromyces sp. E2 resulted in the isolation of cDNAs encoding malate dehydrogenase, aconitase and acetohydroxyacid reductoisomerase. Phylogenetic analysis of the deduced amino acid sequences revealed that they are closely related to their mitochondrial homologues from aerobic eukaryotes. However, the deduced sequences lack N-terminal extensions, which function as mitochondrial leader sequences in the corresponding mitochondrial enzymes from aerobic eukaryotes. Subcellular fractionation and enzyme assays confirmed that the corresponding enzymes are located in the cytosol. As anaerobic chytrids evolved from aerobic, mitochondria-bearing ancestors, we suggest that, in the course of the adaptation from an aerobic to an anaerobic lifestyle, mitochondrial enzymes were retargeted to the cytosol with the concomitant loss of their N-terminal leader sequences