Composition and Gender Distribution of Editorial Boards for Top Neurosurgical Journals.

BACKGROUND: Though women now comprise approximately 21.5% of all neurosurgery residents in the United States, women only represent 10% of practicing neurosurgeons nationally. Serving as a journal editor is 1 measure of academic success. We investigated characteristics of editorial boards for top neurosurgical journals to identify factors influencing membership on editorial boards. We sought to identify gender differences to explain the paucity of women on editorial boards. METHODS: This is a cross-sectional study of editorial boards for the top 10 English-language neurosurgical journals. Data were obtained from journal websites, program faculty lists, or physician online profiles. Gender differences were compared using Student t test and χ2 analysis. RESULTS: Seven hundred twenty-two editorial board members were examined (female n = 65; male n = 650; unidentified n = 7). Overall, women had fewer years in practice (P = 0.002) and more often had additional advanced degrees (P = 0.009) while men had higher h-indices (P < 0.0001). Within the boards of Neurosurgery and Acta Neurochirurgica, men had been in practice longer (P = 0.014; P = 0.023) and had higher h-indices (P = 0.003; P = 0.025). Male editors for Journal of Neurosurgery: Spine and World Neurosurgery had higher h-indices (P = 0.007; P = 0.018). CONCLUSIONS: Women constitute ∼9% of editorial boards for top neurosurgical journals, a percentage comparable to the amount of practicing female academic neurosurgeons. This finding is encouraging as in that there appears to be no readily identifiable bias in the selection of editorial board members. The differences in years in practice and h-index suggest that gender distribution may equalize with time as more women enter practice and produce scientific literature. Efforts to recruit and retain women in neurosurgery should be pursued to rectify this discrepancy.

Clinical Trials in Breast Cancer: Practice Changing, Landmark with a Focus on More Current Trials.

Randomized clinical trials have been essential in guiding the surgical and systemic treatment of breast cancer, with most focusing on de-escalation. Here, we discuss key clinical trials that have shaped the modern approach to the treatment of breast cancer, focusing on studies that are more recent.

Black-Spot Toxicodendron Dermatitis With Varied Presentation.

This article describes the clinical presentation, differential diagnosis, and treatment of 2 unrelated cases with different presentations of black-spot Toxicodendron dermatitis. In the first case, a healthy 7-y-old male presented with a rash consisting of black dots with localized surrounding erythema on the left arm. The rash then progressed to a vesicular, pinpoint, raised rash spreading to the face, arms, and neck. In the second case, a 4-y-old male presented with non-pruritic, black, flat, non-erythematous lesions that did not progress. This patient's older sibling had been diagnosed with poison ivy 1 wk prior, and they attended the same child care where the poison ivy was thought to be acquired. In both cases, diagnosis of black-spot Toxicodendron dermatitis was made. The black spot of Toxicodendron dermatitis is caused by urushiol oxidation on exposure to air. The subject may or may not go on to develop allergic contact dermatitis after the exposure. Diagnosis of this dermatitis is made on clinical presentation, with careful consideration of history, distribution, and lesion morphology. When allergic dermatitis does develop as in the first case, systemic treatment with oral steroids is recommended. In both of these cases the black dots completely resolved in 2 to 3 wk. Dermatologic referral for dermoscopy and biopsy may be necessary if the dermatosis does not resolve as anticipated.

Comparison and evolution of transcranial versus endoscopic endonasal approaches for suprasellar Meningiomas: A systematic review.

BACKGROUND: Meningiomas of the tuberculum sellae (TS) and planum sphenoidale (PS) are challenging to treat surgically. Transcranial approaches (TCAs) were the mainstay before endoscopic endonasal approaches (EEA) were developed, however the efficacy and safety of EEA approaches relative to TCA approaches remains unclear. METHODS: The authors conducted a PRISMA-compliant systematic review of existing literature detailing the outcomes of both approaches. PubMed, Embase, Cochrane Library, and Clinicaltrials.gov were searched. Studies were included if they analyzed TS and/or PS meningiomas, included ≥ 5 patients, and reported at least one outcome of interest. RESULTS: Overall, 44 retrospective studies met inclusion criteria, the majority being from single centers, between 2004 and 2020. In studies directly comparing postoperative outcomes among TCA and EEA approaches, EEA had significantly higher odds of visual improvement (OR = 3.24, p = 0.0053) and significantly higher odds of CSF leak (OR = 3.71, p = 0.0098) relative to TCA. Further, there were no significant differences between visual worsening (p = 0.17), complications (p = 0.51), and GTR rates (p = 0.30) for the two approaches. Meta-analysis demonstrated no significant association between nasoseptal flap (NSF) use and postoperative outcomes among EEA patients. There was also no significant association between study publication year and postoperative EEA outcomes. CONCLUSION: The present study demonstrates that EEA offers a viable alternative to TCA in the treatment of suprasellar meningiomas. In particular, EEA shows promise for superior visual outcomes, though postoperative CSF leaks are an important consideration among patients undergoing this approach.

Gender Equity of Promoting Practices in Academic Neurosurgery in the United States.

BACKGROUND: Women have historically been underrepresented in academic medicine, particularly in surgical subspecialties. This study investigated potential associations between gender and promoting practices in academic neurosurgery. METHODS: Faculty data, including time from residency, professorship, specialty, and h-index, were obtained from websites of the institutions listed in the American Association of Neurological Surgeons Neurosurgical Residency Training Program Directory. Demographics, training, and appointments were compared between male and female neurosurgeons. Predictors of professorship, chair, directorship, and division leadership were identified using multivariable models. RESULTS: The study examined 1629 faculty members. Women were more likely to be assistant professors (P < 0.0001), while men were more likely to be full professors (P < 0.0001), hold chair positions (P = 0.007), lead subspecialty divisions (P = 0.008), and have a higher Scopus h-index (P < 0.0001). In a multivariable analysis, years from training (P < 0.001), fellowship (P = 0.009), h-index (P < 0.001), and chair/program director/division leadership position (P < 0.001) were significant positive predictors of full professorship. Holding additional advanced degrees (P = 0.010), leading a subspecialty division (P = 0.005), and having a higher h-index (P = 0.002) positively predicted chair position. However, when accounting for all other factors, gender was not a significant predictor of full professorship, division leadership, chair, or program directorship. CONCLUSIONS: While significantly more men hold leadership positions in U.S. academic institutions, after controlling for contributing variables, there did not appear to be an association between gender and full professorship, division leadership, chair, or program directorship in academic neurosurgery. While the field still has significant work to do to achieve gender equity, these results may serve as encouragement to women who are looking to advance their careers in academic neurosurgery.

A Novel Weave Tether Technique for Proximal Junctional Kyphosis Prevention in 71 Adult Spinal Deformity Patients: A Preliminary Case Series Assessing Early Complications and Efficacy.

BACKGROUND: Proximal junctional kyphosis (PJK) rates may be as high as 69.4% after adult spinal deformity (ASD) surgery. PJK is one of the greatest unsolved challenges in long-segment fusions for ASD and remains a common indication for costly and impactful revision surgery. Junctional tethers may help to reduce the occurrence of PJK by attenuating adjacent-segment stress. OBJECTIVE: To report our experience and assess early safety associated with a novel "weave-tether technique" (WTT) for PJK prophylaxis in a large series of patients. METHODS: This single-center retrospective study evaluated consecutive patients who underwent ASD surgery including WTT between 2017 and 2018. Patient demographics, operative details, standard radiographic measurements, and complications were analyzed. RESULTS: A total of 71 patients (mean age 66 ± 12 yr, 65% women) were identified. WTT included application to the upper-most instrumented vertebrae (UIV) + 1 and UIV + 2 in 38(53.5%) and 33(46.5%) patients, respectively. No complications directly attributed to WTT usage were identified. For patients with radiographic follow-up (96%; mean duration 14 ± 12 mo), PJK occurred in 15% (mean 1.8 ± 1.0 mo postoperatively). Proximal junctional angle increased an average 4° (10° to 14°, P = .004). Rates of symptomatic PJK and revision for PJK were 8.8% and 2.9%, respectively. CONCLUSION: Preliminary results support the safety of the WTT for PJK prophylaxis. Approximately 15% of patients developed radiographic PJK, no complications were directly attributed to WTT usage, and the revision rate for PJK was low. These early results warrant future research to assess longer-term efficacy of the WTT for PJK prophylaxis in ASD surgery.

Reduced occurrence of primary rod fracture after adult spinal deformity surgery with accessory supplemental rods: retrospective analysis of 114 patients with minimum 2-year follow-up.

OBJECTIVE: Rod fracture (RF) after adult spinal deformity (ASD) surgery is reported in approximately 6.8%-33% of patients and is associated with loss of deformity correction and higher reoperation rates. The authors' objective was to determine the effect of accessory supplemental rod (ASR) placement on postoperative occurrence of primary RF after ASD surgery. METHODS: This retrospective analysis examined patients who underwent ASD surgery between 2014 and 2017 by the senior authors. Inclusion criteria were age > 18 years, ≥ 5 instrumented levels including sacropelvic fixation, and diagnosis of ASD, which was defined as the presence of pelvic tilt ≥ 25°, sagittal vertical axis ≥ 5 cm, thoracic kyphosis ≥ 60°, coronal Cobb angle ≥ 20°, or pelvic incidence to lumbar lordosis mismatch ≥ 10°. The primary focus was patients with a minimum 2-year follow-up. RESULTS: Of 148 patients who otherwise met the inclusion criteria, 114 (77.0%) achieved minimum 2-year follow-up and were included (68.4% were women, mean age 67.9 years, average body mass index 30.4 kg/m2). Sixty-two (54.4%) patients were treated with traditional dual-rod construct (DRC), and 52 (45.6%) were treated with ASR. Overall, the mean number of levels fused was 11.7, 79.8% of patients underwent Smith-Petersen osteotomy (SPO), 19.3% underwent pedicle subtraction osteotomy (PSO), and 66.7% underwent transforaminal lumbar interbody fusion (TLIF). Significantly more patients in the DRC cohort underwent SPO (88.7% of the DRC cohort vs 69.2% of the ASR cohort, p = 0.010) and TLIF (77.4% of the DRC cohort vs 53.8% of the ASR cohort, p = 0.0001). Patients treated with ASR had greater baseline sagittal malalignment (12.0 vs 8.6 cm, p = 0.014) than patients treated with DRC, and more patients in the ASR cohort underwent PSO (40.3% vs 1.6%, p < 0.0001). Among the 114 patients who completed follow-up, postoperative occurrence of RF was reported in 16 (14.0%) patients, with mean ± SD time to RF of 27.5 ± 11.8 months. There was significantly greater occurrence of RF among patients who underwent DRC compared with those who underwent ASR (21.0% vs 5.8%, p = 0.012) at comparable mean follow-up (38.4 vs 34.9 months, p = 0.072). Multivariate analysis demonstrated that ASR had a significant protective effect against RF (OR 0.231, 95% CI 0.051-0.770, p = 0.029). CONCLUSIONS: This study demonstrated a statistically significant decrease in the occurrence of RF among ASD patients treated with ASR, despite greater baseline deformity and higher rate of PSO. These findings suggest that ASR placement may provide benefit to patients who undergo ASD surgery.

Posterior Polyethylene Tethers Reduce Occurrence of Proximal Junctional Kyphosis After Multilevel Spinal Instrumentation for Adult Spinal Deformity: A Retrospective Analysis.

BACKGROUND: Proximal junctional kyphosis (PJK) is a common postoperative complication after adult spinal deformity (ASD) surgery and may manifest with neurological decline, worsening spinal deformity, and spinal instability, which warrant reoperation. Rates of PJK may be as high as 69.4% after ASD surgery. OBJECTIVE: To evaluate the efficacy of junctional tethers for PJK prophylaxis after multilevel instrumented surgery for ASD with minimum 2-yr follow-up. METHODS: Single-center retrospective analysis of adult patients (age ≥18 yr) who underwent ASD surgery with index operations performed between November 2010 and June 2016 and achieved minimum 2-yr follow-up. Patients with ASD were subdivided into 3 treatment cohorts based on institutional protocol: no tether (NT), polyethylene tether-only (TO), and tether with crosslink (TC). PJK was defined as a proximal junctional angle (PJA) >10° and 10° greater than the corresponding preoperative measurement. Patient demographics, operative details, standard radiographic scoliosis measurements (including PJA and assessment of PJK), and complications were analyzed. RESULTS: Of 184 patients, 146 (79.3%) achieved minimum 2-yr follow-up (mean = 45 mo; mean age = 67 yr; 67.8% women). PJK rates reported for the NT, TO, and TC cohorts were 60.7% (37/61), 35.7% (15/42), and 23.3% (10/43), respectively. PJK rates among TC patients were significantly lower than NT (P = .01601). CONCLUSION: Junctional tethers with crosslink significantly reduced the incidence of PJK and revisions for PJK among ASD patients treated with long-segment posterior instrumented fusions who achieved minimum 2-yr follow-up.

Tele-robotics and artificial-intelligence in stroke care.

In the last forty years, the field of medicine has experienced dramatic shifts in technology-enhanced surgical procedures - from its initial use in 1985 for neurosurgical biopsies to current implementation of systems such as magnetic-guided catheters for endovascular procedures. Systems such as the Niobe Magnetic Navigation system and CorPath GRX have allowed for utilization of a fully integrated surgical robotic systems for perioperative manipulation, as well as tele-controlled manipulation systems for telemedicine. These robotic systems hold tremendous potential for future implementation in cerebrovascular procedures, but lack of relevant clinical experience and uncharted ethical and legal territory for real-life tele-robotics have stalled their adoption for neurovascular surgery, and might present significant challenges for future development and widespread implementation. Yet, the promise that these technologies hold for dramatically improving the quality and accessibility of cerebrovascular procedures such as thrombectomy for acute stroke, drives the research and development of surgical robotics. These technologies, coupled with artificial intelligence (AI) capabilities such as machine learning, deep-learning, and outcome-based analyses and modifications, have the capability to uncover new dimensions within the realm of cerebrovascular surgery.