Race and socioeconomic disparities persist in treatment and outcomes of patients with cervical spinal cord injuries: An analysis of the national inpatient sample from 2016 - 2020.

Objective: Previous literature has described race and socioeconomic disparities in both treatment and outcomes following cervical spinal cord injuries (SCI). The goal of this study is to investigate the current state of parity in management and outcomes following SCI. Methods: We surveyed the National Inpatient Sample database (NIS) for patients admitted with primary diagnosis of cervical SCI. 49,320 patients were identified. Univariate and multivariate analyses were performed to evaluate racial and socioeconomic differences in SCI care and outcomes. Results: Compared to white patients, minority race was associated with a longer time from presentation to operative intervention (p < 0.001) and longer length of stay following admission for cervical SCI (16 vs 13 days, p < 0.001). Minority patients were more likely to have an unfavorable discharge (skilled nursing facility, against medical advice, death) status than white patients (p < 0.001). Patients in the bottom quartile of median household income were associated with more unfavorable discharges than the top two quartiles (p < 0.001). Patients with the lowest median household income quartile also had higher total costs than those in the top quartiles ($221,654 vs 191,723, p < 0.001). Black, Hispanic, and Asian/Pacific Islander incurred higher treatment costs than White patients. Conclusion: Minority and lower socioeconomic status are independently associated with unfavorable discharge and LOS in cervical SCI. Furthermore, racial and economically disadvantaged groups have longer wait times from admission to surgical intervention. These disparities persist despite being highlighted by previous publications and increased societal awareness of healthcare inequities, necessitating further work to reach parity.

Association of geographical disparities and segregation in regional treatment facilities for Black patients with aneurysmal subarachnoid hemorrhage in the United States.

Background and objectives: This study investigates geographic disparities in aneurysmal subarachnoid hemorrhage (aSAH) care for Black patients and aims to explore the association with segregation in treatment facilities. Understanding these dynamics can guide efforts to improve healthcare outcomes for marginalized populations. Methods: This cohort study evaluated regional differences in segregation for Black patients with aSAH and the association with geographic variations in disparities from 2016 to 2020. The National Inpatient Sample (NIS) database was queried for admission data on aSAH. Black patients were compared to White patients. Segregation in treatment facilities was calculated using the dissimilarity (D) index. Using multivariable logistic regression models, the regional disparities in aSAH treatment, functional outcomes, mortality, and end-of-life care between Black and White patients and the association of geographical segregation in treatment facilities was assessed. Results: 142,285 Black and White patients were diagnosed with aSAH from 2016 to 2020. The Pacific division (D index = 0.55) had the greatest degree of segregation in treatment facilities, while the South Atlantic (D index = 0.39) had the lowest. Compared to lower segregation, regions with higher levels of segregation (global F test p < 0.001) were associated a lower likelihood of mortality (OR 0.91, 95% CI 0.82-1.00, p = 0.044 vs. OR 0.75, 95% CI 0.68-0.83, p < 0. 001) (p = 0.049), greater likelihood of tracheostomy tube placement (OR 1.45, 95% CI 1.22-1.73, p < 0.001 vs. OR 1.87, 95% CI 1.59-2.21, p < 0.001) (p < 0. 001), and lower likelihood of receiving palliative care (OR 0.88, 95% CI 0.76-0.93, p < 0.001 vs. OR 0.67, 95% CI 0.59-0.77, p < 0.001) (p = 0.029). Conclusion: This study demonstrates regional differences in disparities for Black patients with aSAH, particularly in end-of-life care, with varying levels of segregation in regional treatment facilities playing an associated role. The findings underscore the need for targeted interventions and policy changes to address systemic healthcare inequities, reduce segregation, and ensure equitable access to high-quality care for all patients.

The impact of historical redlining on neurosurgeon distribution and reimbursement in modern neighborhoods.

Background: This study examines the lasting impact of historical redlining on contemporary neurosurgical care access, highlighting the need for equitable healthcare in historically marginalized communities. Objective: To investigate how redlining affects neurosurgeon distribution and reimbursement in U.S. neighborhoods, analyzing implications for healthcare access. Methods: An observational study was conducted using data from the Center for Medicare and Medicaid Services (CMS) National File, Home Owner's Loan Corporation (HOLC) neighborhood grades, and demographic data to evaluate neurosurgical representation across 91 U.S. cities, categorized by HOLC Grades (A, B, C, D) and gentrification status. Results: Of the 257 neighborhoods, Grade A, B, C, and D neighborhoods comprised 5.40%, 18.80%, 45.8%, and 30.0% of the sample, respectively. Grade A, B, and C neighborhoods had more White and Asian residents and less Black residents compared to Grade D neighborhoods (p < 0.001). HOLC Grade A (OR = 4.37, 95%CI: 2.08, 9.16, p < 0.001), B (OR = 1.99, 95%CI: 1.18, 3.38, p = 0.011), and C (OR = 2.37, 95%CI: 1.57, 3.59, p < 0.001) neighborhoods were associated with a higher representation of neurosurgeons compared to Grade D neighborhoods. Reimbursement disparities were also apparent: neurosurgeons practicing in HOLC Grade D neighborhoods received significantly lower reimbursements than those in Grade A neighborhoods ($109,163.77 vs. $142,999.88, p < 0.001), Grade B neighborhoods ($109,163.77 vs. $131,459.02, p < 0.001), and Grade C neighborhoods ($109,163.77 vs. $129,070.733, p < 0.001). Conclusion: Historical redlining continues to shape access to highly specialized healthcare such as neurosurgery. Efforts to address these disparities must consider historical context and strive to achieve more equitable access to specialized care.

The Role of County-Level Persistent Poverty in Stroke Mortality in the USA.

Stroke is a major health concern in the USA, disproportionately affecting socioeconomically disadvantaged groups. This study investigates the link between persistent poverty and stroke mortality rates in residents aged 65 and above, positing that sustained economic challenges at the county level correlate with an increase in stroke-related deaths. Persistent poverty refers to a long-term state where a significant portion of a population lives below the poverty threshold for an extended period, typically measured over several decades. It captures the chronic nature of economic hardship faced by a community across multiple generations. Utilizing data from the CDC Wonder database and the American Community Survey, we conducted a comprehensive analysis across US counties, differentiating them by persistent poverty status. Our results indicate a statistically significant link between persistent poverty and increased mortality from ischemic and hemorrhagic strokes; counties afflicted by long-standing poverty were associated with an additional 33.49 ischemic and 8.16 hemorrhagic stroke deaths per 100,000 residents annually compared to their wealthier counterparts. These disparities persisted when controlling for known stroke risk factors and other socioeconomic variables. These results highlight the need for targeted public health strategies and interventions to address the disparities in stroke mortality rates and the broader implications for healthcare equity. The study underscores the vital role of socioeconomic context in health outcomes and the urgency of addressing long-term poverty as a key determinant of public health.

Gender parity in neurosurgery residencies: an analysis.

OBJECTIVE: The number of women graduating from United States medical schools has reached parity with that of men. However, persistent inequalities and barriers have slowed the pace toward equity in application and representation in neurosurgery residency despite initiatives to increase female representation. The objective of the present study was to assess the advancement of gender parity within neurosurgery residency programs. Additionally, the study aimed to analyze the pipeline dynamics by investigating the effects of attrition on women in neurosurgery, as well as exploring the patterns of female applications to neurosurgery residency programs versus other surgical specialties. METHODS: Data on the number of active female neurosurgery residents and female applicants to neurosurgery were collected from the Accreditation Council for Graduate Medical Education Data Resource Book from 2007 to 2021 and Electronic Residency Application Service from 2014 to 2022. Linear regression analysis was used to predict the percent of active female residents based on academic year (AY). A Pearson chi-square test was used to determine the odds of a female applying to neurosurgery. RESULTS: The percent of active female residents in neurosurgery increased from 11.0% in 2007 to 21.8% in 2021. Bivariate linear regression analysis using AY as a predictor of the percent of active females showed a statistically significant correlation. On average, the percent of active female residents increased by 0.65% per year. If trends persist, parity for females in neurosurgery will not be reached until 2069. Linear regression analysis of the overall rate of attrition in neurosurgery as a predictor of the percent of active female residents revealed that for every 1% increase in the rate of attrition, the percent of active female residents decreased by 2.91% (p = 0.001). The percent of female applicants to neurosurgery increased from 19.6% in 2014 to 29.8% in 2022 (p = 0.009), yet the odds of a female applying to neurosurgery remain low. CONCLUSIONS: Neurosurgery continues to struggle with the recruitment of female medical students even as parity has been reached for female medical school matriculants. Greater effort is needed to recruit and retain female applicants to neurosurgery, including increased transparency in match and attrition metrics.

Virtual Interviews During COVID-19 Changed Neurosurgery Match-for Better or Worse.

OBJECTIVE: The COVID-19 pandemic forced neurosurgery residency application processes to adopt a virtual interview model. This study analyzes the trends in program and applicant residency match behavior due to virtual interviews. METHODS: National Resident Matching Program data from Main Residency Match, National Resident Matching Program Director and Applicant Survey, Electronic Residency Application Service, and Charting Outcomes in the Match were collected for neurosurgery residents for all available years, providing information on neurosurgery residency application, interview, and match outcomes. Studied years were dichotomized to account for virtual versus in-person interviews and analyzed for differences. RESULTS: Although the average number of applications received during in-person versus virtual years was not statistically different, 245 versus 290 (P = 0.115), programs interviewed more applicants when interviews were virtual, 37.2 versus 46, (P = 0.008). Similarly, matched U.S. senior applicants did not submit a statistically higher number of applications in person versus virtual, 54 versus 77 (P = 0.055), but they did attend more interviews virtually, 20.5 versus 16.6 (P = 0.013), and ranked more programs, 20 versus 16.2 (P = 0.002). Although White applicants did not have a statistically significant difference in number of applications submitted (55 vs. 68, P = 0.129), Black applicants submitted more applications during virtual match compared with in-person match (52 vs. 74, P = 0.012). The number of applicants that programs needed to rank to fill each position was not statistically different when comparing in-person versus virtually conducted interviews, 4.6 versus 5.4 (P = 0.070). CONCLUSIONS: Despite no change in the overall number of applications submitted per applicant, Black applicants submitted more applications virtually, suggesting potential benefits of virtual format for Black applicants. Interview format was strongly correlated to the use of perceived fitness by applicants in rank decision making. Virtual interviews provide major financial advantages to candidates and could help improve Black representation in neurosurgery. However, they impose limitations on ability access fitness.

Race and socioeconomic disparities in mortality and end-of-life care following aneurysmal subarachnoid hemorrhage.

BACKGROUND: This study explores racial and socioeconomic disparities in aneurysmal subarachnoid hemorrhage (aSAH) care, highlighting the impact on treatment and outcomes. The study aims to shed light on inequities and inform strategies for reducing disparities in healthcare delivery. METHODS: In this cohort study the National Inpatient Sample database was queried for patient admissions with ruptured aSAH from 2016 to 2020. Multivariable analyses were performed estimating the impact of socioeconomic status and race on rates of acute treatment, functional outcomes, mortality, receipt of life-sustaining interventions (mechanical ventilation, tracheostomy, gastrostomy, and blood transfusions), and end-of-life care (palliative care and do not resuscitate). RESULTS: A total of 181 530 patients were included. Minority patients were more likely to undergo treatment (OR 1.15, 95% CI 1.09 to 1.22, P<0.001) and were less likely to die (OR 0.89, 95% CI 0.84 to 0.95, P<0.001) than White patients. However, they were also more likely to have a tracheostomy (OR 1.47, 95% CI 1.33 to 1.62, P<0.001) and gastrostomy tube placement (OR 1.43, 95%CI 1.32 to 1.54, P<0.001), while receiving less palliative care (OR 0.75, 95% CI 0.70 to 0.80, P<0.001). This trend persisted when comparing minority patients from wealthier backgrounds with White patients from poorer backgrounds for treatment (OR 1.10, 95% CI 1.00 to 1.21, P=0.046), mortality (OR 0.82, 95% CI 0.74 to 0.89, P<0.001), tracheostomy tube (OR 1.27, 95% CI 1.07 to 1.48, P<0.001), gastrostomy tube (OR 1.34, 95% CI 1.18 to 1.52, P<0.001), and palliative care (OR 0.76, 95% CI 0.69 to 0.84, P<0.001). CONCLUSIONS: Compared with White patients, minority patients with aSAH are more likely to undergo acute treatment and have lower mortality, yet receive more life-sustaining interventions and less palliation, even in higher socioeconomic classes. Addressing these disparities is imperative to ensure equitable access to optimal care and improve outcomes for all patients regardless of race or class.

Using pre-surgical suspicion to guide insula implantation strategy.

Rationale: Insular epilepsy can be a challenging diagnosis due to overlapping semiology and scalp EEG findings with frontal, temporal, and parietal lobe epilepsies. Stereotactic electroencephalography (sEEG) provides an opportunity to better localize seizure onset. The possibility of improved localization is balanced by implantation risk in this vascularly rich anatomic region. We review both safety and pre-implantation factors involved in insular electrode placement across four years at an academic medical center. Methods: Presurgical data, operative reports, and invasive EEG summaries were retrospectively reviewed for patients undergoing invasive epilepsy monitoring on the insula from 2016 through 2019. EEG reports were reviewed to record the presence of insula ictal and interictal involvement. We recorded which presurgical findings suggested insular involvement (insula lesion on MRI, insula changes on PET/SPECT/scalp EEG, characteristic semiology, or history of failed anterior temporal lobectomy). The likelihood of pre-sEEG insular onset was categorized as low suspicion if no presurgical findings were present ("rule out"), moderate suspicion if one finding was present, and high suspicion if two or more findings were present. Results: 76 patients received 189 insular electrodes as part of their implantation strategy for 79 surgical cases. Seven patients (8.9%) had insular ictal onset. One clinically significant complication (left hemiparesis) occurred in a patient with moderate suspicion for insular onset. There were 38 low suspicion cases, 36 moderate suspicion cases, and 5 high suspicion cases for pre-sEEG insula ictal onset. Two low suspicion (5.3%), three moderate suspicion (8.6%), and two high suspicion (40%) cases had insular ictal onset. Conclusions: The insula can safely receive sEEG. Having two or more presurgical factors indicating insular onset is a strong, albeit incomplete, predictor of insular seizure onset. Using pre-implantation clinical findings can offer clinicians predictive value for targeting the insula during invasive EEG monitoring.

Neurosurgery Resident Attrition Rates Defy Trends and Decrease During COVID-19 Pandemic.

OBJECTIVE: We sought to determine the effects of the coronavirus disease 2019 (COVID-19) pandemic on U.S. neurosurgery resident attrition. We report the changes in resident attrition due to transfers, withdrawal, or dismissal from program training during the COVID-19 pandemic. METHODS: Neurosurgery resident attrition data reported by the American Council of Graduate Medical Education for the academic year starting in July 2007 to the academic year ending in June 2022 were collected, and the rate of attrition was calculated. Individual postgraduate year program transfer rates were also calculated for the previous 7 consecutive academic years. The attrition rates for the academic years before the pandemic were compared with those during the pandemic. RESULTS: A total of 465 residents did not graduate from neurosurgical training during the past 15 academic years, of which 3 years were at least partially during the COVID-19 pandemic, resulting in a mean attrition rate of 2.5%. The attrition rates during the pandemic were lower than those before the pandemic (1.7% vs. 2.7%; P < 0.001), driven largely by a nearly twofold decrease in the withdrawal rate (0.67% vs. 1.2%; P = 0.003). Bivariate regression between the withdrawal and attrition rates showed a statistically significant correlation (r = 0.809; P < 0.001; r2 = 0.654). The first full year of the COVID-19 pandemic saw the most dramatic changes, with a z score for attrition of -1.9. Linear regression of the effect of training during the COVID-19 pandemic on attrition revealed a statistically significant difference (r = 0.563; P = 0.029; r2 = 0.317). The rate of withdrawal was most affected by training during the pandemic (r = 0.594; P = 0.010; r2 = 0.353). CONCLUSIONS: A statistically significant decline occurred in the rate of neurosurgery resident attrition during the COVID-19 pandemic that was most notable during the first full academic year (2020-2021). These findings were largely driven by a decrease in residents withdrawing from training programs. This contrasts with the overall trend toward resignation among healthcare workers during the pandemic. It is unclear what enduring ramifications this will have on neurosurgery residencies moving forward and whether we will see higher attrition rates as we transition toward a new normal. Future studies should examine trends in the attrition rates after the COVID-19 pandemic and determine the long-term effects of decreased attrition rates of residents during the pandemic.

Metastatic esthesioneuroblastoma with widespread recurrence to the central nervous system.

Background: Esthesioneuroblastomas (ENBs) are rare malignancies of the upper digestive tract, often demonstrating local metastasis to the intracranial space through the cribriform plate. These tumors show high rates of recurrence locally following treatment. Here, we report a patient with advanced recurrent ENB 2 years following initial treatment, affecting both the spine and intracranial space without evidence of local recurrence or contiguous extension from the initial tumor site. Case Description: A 32-year-old male presents with a 2 month history of neurological symptoms 2 years following treatment of Kadish C/AJCC stage IVB (T4a, N3, M0) ENB. No evidence of locoregional recurrent disease was observed prior with intermittent imaging. Imaging revealed a large ventral epidural tumor invading multiple levels of the thoracic spine as well as a ring enhancing lesion in the right parietal lobe. The patient was treated surgically with debridement, decompression, and posterior stabilization of the thoracic spine followed by radiotherapy to the spinal and parietal lesions. Chemotherapy was also initiated. Despite treatment, the patient passed away 6 months after surgery. Conclusion: We report a case of delayed recurrent ENB with widespread metastases to the central nervous system without evidence of local disease or contiguous extension from initial tumor site. This represents a highly aggressive form of this tumor as recurrences are primarily locoregional. In follow-up of ENB treatment, clinicians must be cognizant of these tumors demonstrated ability to spread to distal regions. All new onset neurological symptoms should be investigated fully even if no local recurrence is observed.

Evaluating Match and Attrition Rates for Women and African Americans in Neurosurgery.

BACKGROUND: Previous efforts to increase diversity in neurosurgery have been aimed primarily at female inclusion while little analysis of other under-represented groups has been performed. OBJECTIVE: To evaluate match and retention rates of under-represented groups in neurosurgery, specifically Black and female applicants compared with non-Black and male applicants. METHODS: Match lists, Electronic Residency Application Service data, and National Resident Matching Program data were retrospectively reviewed along with publicly available residency program information for successful matriculants from 2017 to 2020. Residents were classified into demographic groups, and analysis of match and retention rates was performed. RESULTS: For 1780 applicants from 2017 to 2020, 439 identified as female while 1341 identified as male. Of these 1780 applicants, 128 identified as Black and 1652 identified as non-Black. Male and female applicants matched at similar rates ( P = .76). Black applicants matched at a lower rate than non-Black applicants ( P < .001). From 2017 to 2020, neither race nor sex was associated with retention as 94.1% of male applicants and 93.2% of female applicants were retained ( P = .63). In total, 95.2% of Black residents and 93.9% of non-Black residents were retained ( P = .71). No intraregional or inter-regional differences in retention were found for any group. CONCLUSION: Although sex parity has improved, Black applicants match at lower rates than non-Black applicants but are retained after matriculation at similar rates. Neurosurgery continues to recruit fewer female applicants than male applicants. More work is needed to extend diversity to recruit under-represented applicants. Future studies should target yearly follow-up of retention and match rates to provide trends as a measure of diversification progress within the field.

Incidence of Intracranial Melanoma Progression in the Setting of Positive Extracranial Response to Targeted Therapy and Immunotherapy: An Indication for More Frequent Screening in This Population?

Background and objective The incidence of intracranial metastases from melanoma is on the rise. In this study, we aimed to determine the incidence of intracranial disease progression in patients on BRAF/MEK targeted therapy and immunotherapy in the setting of controlled or improving extracranial disease. Methods This was a single-center, retrospective review that involved patients who underwent stereotactic radiosurgery (SRS) for intracranial metastatic melanoma between January 1, 2014, and December 31, 2018. We focused on BRAF/MEK mutation status and dates of treatment with BRAF/MEK targeted therapy, immunotherapy [ipilimumab (Yervoy), nivolumab (Opdivo), or pembrolizumab (Keytruda)], and combination targeted and immunotherapy. Results A total of 51 patients were enrolled: 36 males and 15 females. The average age of the patients was 58.6 years, and 26 among them were BRAF mutation-positive. Seventeen had prior surgery with SRS as adjuvant therapy. The other 34 had SRS as primary treatment. Forty-two patients had extracranial disease present at the time of SRS. There were 34 patients treated with targeted and immune therapy. Overall, 16 patients (47.1%) demonstrated controlled or improving extracranial disease, and 18 (52.9%) demonstrated progressing extracranial disease at the time of SRS. In the subgroup analysis, patients treated with BRAF/MEK targeted therapy demonstrated a 75% rate of extracranial disease control. The extracranial disease was controlled in 43.75% of patients on immunotherapy with intracranial progression, while it was controlled in 30% of patients on both BRAF/MEK targeted therapy and immunotherapy with intracranial progression. Sixteen patients (47.1%) developed intracranial metastasis in our study while having a stable systemic disease with BRAF/MEK targeted therapy, immunotherapy, or a combination of the two. Conclusion Based on our findings, a systemic response to targeted therapy and immunotherapy does not necessarily parallel intracranial protection.

Delayed Cranial Nerve Palsies and Chiari Type I Malformation After Epidural Anesthesia in the Setting of Childbirth.

Epidural analgesia is an efficient method of controlling pain and has a wide spectrum of therapeutic and diagnostic applications. Potential complications may occur in a delayed fashion, can remain undiagnosed, and can be a source of significant morbidity. We present a 37-year-old woman presented with severe spontaneous occipital headaches, diplopia, and dizziness that occurred spontaneously six weeks after giving birth. Her primary method of pain control during labor was epidural analgesia. Her neurologic exam revealed a cranial nerve six palsy with ptosis, and her brain MRI demonstrated a Chiari I malformation which had not been previously diagnosed. CT myelography of the lumbar spine revealed extradural contrast extravasation within the interspinous soft tissue at L1-L2, which was the site of her prior epidural procedure. She underwent epidural blood patch administration, and her cranial nerve palsy resolved along with all of her other symptoms. The development of concurrent Chiari I malformation and cranial nerve palsy after epidural anesthesia is an exceptionally rare occurrence. Neurologic complications after epidural anesthesia are likely under-reported, since patients are often lost to follow-up or have subtle neurologic signs which can easily be missed. This frequently delayed presentation emphasizes the importance of patient education and the necessity of a detailed neurological exam when symptoms occur.

Successful Novel Treatment of a Paraspinal Primitive Neuroectodermal Tumor with Predominantly Glial Differentiation: A 3-Year Follow-Up After Surgery, Intensity-Modulated Radiation Therapy and Oral Temozolomide.

BACKGROUND: Paraspinal masses are a relatively uncommon but diverse group of lesions that can be neoplastic or non-neoplastic. Peripheral primitive neuroectodermal tumors of the lumbar paraspinal region with diffuse and strong glial differentiation have never been reported before. CASE DESCRIPTION: We report a primary paraspinal primitive neuroectodermal tumor with overwhelming glial differentiation in a 23-year-old female patient who presented with intractable right lower extremity pain. The patient underwent a 2-staged operation with gross total resection of the mass followed by intensity-modulated radiation therapy and oral temozolomide, a regimen employed for high-grade intracranial gliomas. Serial imaging revealed no evidence of recurrence after 3 years. CONCLUSIONS: Although these lesions appear to be exceptionally rare, an approach similar to that of intracranial high-grade glial tumors was effective in our experience. Our patient had no evidence of recurrence at 3-year follow-up.