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

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

Embodiment in Neuro-Engeneering Endeavours: Phenomenological Considerations and Practical Implications

The field of Neuro-Engineering seems to be on the fast track towards accomplishing its ultimate goal of potentially replacing the nervous system in the face of disease. Meanwhile, the patients and professionals involved are continuously dealing with human bodily experience and especially how neuro-engineering devices could become part of a user’s body schema: the domain of ‘embodied phenomenology’. This focus on embodiment, however, is not sufficiently reflected in the current literature on ethical and philosophical issues in neuro-engineering. In this article we will focus on this lacuna by explaining existing data on neuro-engineering user’s experiences by using phenomeno

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

Case report: High-resolution, intra-operative µDoppler-imaging of spinal cord hemangioblastoma

Surgical resection of spinal cord hemangioblastomas remains a challenging endeavor: the neurosurgeon’s aim to reach total tumor resections directly endangers their aim to minimize post-operative neurological deficits. The currently available tools to guide the neurosurgeon’s intra-operative decision-making consist mostly of pre-operative imaging techniques such as MRI or MRA, which cannot cater to intra-operative changes in field of view. For a while now, spinal cord surgeons have adopted ultrasound and its submodalities such as Doppler and CEUS as intra-operative techniques, given their many benefits such as real-time feedback, mobility and ease of use. However, for highly vascularized lesions such as hemangioblastomas, which contain up to capillary-level microvasculature, having access to higher-resolution intra-operative vascular imaging could potentially be highly beneficial. µDoppler-imaging is a new imaging modality especially fit for high-resolution hemodynamic imaging. Over the last decade, µDoppler-imaging has emerged as a high-resolution, contrast-free sonography-based technique which relies on High-Frame-Rate (HFR)-ultrasound and subsequent Doppler processing. In contrast to conventional millimeter-scale (Doppler) ultrasound, the µDoppler technique has a higher sensitivity to detect slow flow in the entire field-of-view which allows for unprecedented visualization of blood flow down to sub-millimeter resolution. In contrast to CEUS, µDoppler is able to image high-resolution details continuously, without being contrast bolus-dependent. Previously, our team has demonstrated the use of this technique in the context of functional brain mapping during awake brain tumor resections and surgical resections of cerebral arteriovenous malformations (AVM). However, the application of µDoppler-imaging in the context of the spinal cord has remained restricted to a handful of mostly pre-clinical animal studies. Here we describe the first application of µDoppler-imaging in the case of a patient with two thoracic spinal hemangioblastomas. We demonstrate how µDoppler is able to identify intra-operatively and with high-resolution, hemodynamic features of the lesion. In contrast to pre-operative MRA, µDoppler could identify intralesional vascular details, in real-time during the surgical procedure. Additionally, we show highly detailed post-resection images of physiological human spinal cord anatomy. Finally, we discuss the necessary future steps to push µDoppler to reach actual clinical maturity

How I do it: percutaneous transforaminal endoscopic discectomy for lumbar disk herniation

Background: Percutaneous transforaminal endoscopic discectomy (PTED) has emerged as a less invasive technique to treat symptomatic lumbar disk herniation (LDH). PTED is performed under local anesthesia with the advantage of immediate intraoperative feedback of the patient. In this paper, the technique is described as conducted in our hospital. Methods: PTED is performed under local anesthesia in prone position on thoracopelvic supports. The procedure is explained stepwise: e.g. marking, incision, introduction of the 18-gauge needle and guidewire to the superior articular process, introduction of the TomShidi needle and foraminotomy up to 9 mm, with subsequently removal of di

Outcome of non-instrumented lumbar spinal surgery in obese patients: a systematic review

Introduction: Lumbar spinal decompression procedures are well known in their techniques and outcomes. However, outcomes of lumbar spinal surgery in patients with obesity are relatively unknown. The aim of this review is to assess the effect of obesity on post-operative outcomes of lumbar non-instrumented decompressive spinal surgery. Methods and materials: A literature search through PubMed, Embase, Web of Science and Cochrane was performed. Articles were included if they reported outcomes of obese patients after non-instrumented lumbar decompression surgery, if these outcomes were described using patient-reported outcome measures and if there was at least two months of follow-up. Risk of bias was assessed using an adjusted version of the Cowley score. Results: From the 222 unique articles, 14 articles, comprising 13,653 patients, met the inclusion criteria. Eight out of 14 studies had a low risk of bias, while the remaining six had an intermediate risk of bias. Thirteen studies evaluated leg and back pain, and the vast majority demonstrated less decrease in pain in the obese group. Six studies evaluated disability and all but one showed less improvement in obese patients. Five studies evaluated functionality and wellbeing and all but one showed less satisfactory outcome in obese patients. Conclusions: Literature does not reveal a difference in clinical outcome nor in complications in patients undergoing non-instrumented lumbar surgery with a BMI lower than 30 or equal to or higher than 30. This may be used by physicians to inform patients prior to lumbar decompression surgery