Global neurosurgery over a 60-year period: Conceptual foundations, time reference, emerging Co-ordinates and prospects for collaborative interventions in low and middle income countries.

Introduction: We evaluated salient initiatives invested in global neurosurgery over a 60-year period. Research question: What are the Phases, Achievements, Challenges, and Lessons of Global Neurosurgery. Methods: A 60-year retrospective study from 1960 to 2020 analyzing the major phases, lessons, and progress notes. We reviewed the foundational need questions and innovated tools used to answer them. Results: Three phases defining our study period were identified. In the early phase, birthing academic units and the onset of individual volunteerism were dominant concepts. The 2nd phase is summarized by the rise of volunteerism and surgical camps.The third phase is heralded by advocacy and strategies for achieving care equity. The defining moment is the Lancet commission for global surgery summit in 2015. Lessons include the need for evaluation of the resources of recipient and donor locations using novel global surgery tools. Conclusion: Global neurosurgery over the 60-year study period is summarized by indelible touchstones of personal and group efforts as well as triumphs derived from innovations in the face of formidable challenges.

Effectiveness of laminectomy with fusion and laminectomy alone in degenerative cervical myelopathy.

PURPOSE: The effectiveness of laminectomy with fusion and laminectomy alone in degenerative cervical myelopathy was compared. METHODS: Individuals treated with laminectomy with fusion or laminectomy alone at or below the second cervical vertebra were identified in the Swedish spine registry. 66 individuals treated with laminectomy and instrumented fusion were age matched to 132 individuals treated with laminectomy alone. The European Myelopathy Scale (EMS), the Neck Disability Index (NDI), the Numeric Rating Scale (NRS) for neck pain and the EQ-5D index were available at baseline, and at 1 and 2 year follow-ups. Statistical analyses were performed with Mann-Whitney U tests and paired T tests. Effect sizes were described with Cohen's D. RESULTS: Data at baseline did not differ significantly between the groups with the exception of a longer laminectomy in the fusion group (4.2 vs 3.4 vertebras; p < 0.001). Both groups improved EMS, NDI, NRS and EQ-5D from baseline to 1 year (p ≤ 0.011), with no additional improvement between 1 and 2 years (all p ≥ 0.09). Effect sizes for change from baseline were small to medium in both groups. At 2 years the laminectomy with fusion group and the laminectomy alone group had a median (25th;75th percentile) EMS of 13 (11;13) and 13 (11;15) (p = 0.77), NDI of 39 (24;54) and 27 (10;41) (p = 0.045), NRS of 4 (1;2) and 2 (0;5) (p = 0.048), and EQ-5D index of 0.67 (0.25;0.73) and 0.66 (0.17;0.76) (p = 0.96). CONCLUSION: The results of this study suggest similar effectiveness of laminectomy with instrumented fusion and laminectomy alone in degenerative cervical myelopathy. LEVEL OF EVIDENCE: III.

Pilot application of Lecture-Panel-Discussion Model (LPDM) in global collaborative neurosurgical education: a novel training paradigm innovated by the Swedish African Neurosurgery Collaboration.

BACKGROUND: Disruptions in global surgery educational routines by the COVID-19 pandemic have elicited demands for alternative formats for rendering qualitative neurosurgical education. This study presents application of a novel model of online neurosurgical course, the Lecture-Panel-Discussion Model (LPDM). METHODS: This is a cross-sectional survey of participants who attended the Swedish African Neurosurgery Collaboration (SANC)-100A course. Participants evaluated the course through an online self-administered questionnaire using a 5-point Likert scale ranging from very poor-1, poor-2, average (fair)-3, good-4, to excellent-5. SANC-100A comprises a tripod of Lectures, Panel review, and interactive case Discussion. This model (LPDM) was innovated by SANC and applied at the Enugu International Neurosurgery course in February 2021. RESULTS: There were 71 attendees, 19 were course faculty, while 52 were participants. Thirty-five attended from Nigeria, 11 from Sweden, 3 from Malawi, 2 from Senegal, and 1 from the UK. Among 44 participants who completed the questionnaire, there were 9 fellows and 35 residents. The overall median course Likert rating was 4.65 ± 0.1. The median overall rating for course events was similar between day 1 (Likert score = 4.45) and day 2 (Likert score = 4.55), U = 55, Z score = 1.10, P = 0.27. The median rating for lectures was 4.50 ± 0.2 and varied from 4.40 on day 1 to 4.55 on day 2. The median rating for panel review was 4.60 ± 0.1 and varied from 4.55 on day 1 to 4.65 on day 2. Interactive case discussions were rated 4.80 on both course days. There was a significant variability in the rating profiles of the course tripod: U = 24.5, P = 0.03. Fifty-one (98%) participants believe LPDM was COVID-19-compliant, while 90% believe the course was beneficial to training and practice. CONCLUSION: Initial application of LPDM is rewarded with both high acceptance and high rating among participants.

Subaxial Spine Fractures: A Comparison of Patient-reported Outcomes and Complications Between Anterior and Posterior Surgery.

STUDY DESIGN: Observational study on prospectively collected data. OBJECTIVES: The aim of this study was to compare long-term patient-reported outcomes and complications after anterior or posterior cervical spine surgery for subaxial fractures. SUMMARY OF BACKGROUND DATA: There is no consensus in the literature regarding the optimal surgical approach when treating spine fractures in the subaxial region. METHODS: A total of 200 individuals who had been treated with either anterior or posterior surgery due to a subaxial single segment, or single vertebra, injury between 2006 and 2016 and had at least 1 year follow-up were identified in the Swedish Spine register. Cases were matched 1:1 for age (±5 years). Outcomes were Neck Disability Index (NDI) and EQ-5D-3L, and reoperations, mortality, and surgeon- and patient-reported wound complications within 90 days. t Tests and χ2 tests were used statistical comparisons. RESULTS: At follow-up, NDI was 23 (21) in the anterior group and 29 (21) in the posterior group (P = 0.07). EQ-5D-3L index was 0.62 (0.37) in the anterior group and 0.54 (0.39) in the posterior group (P = 0.13). Patient satisfaction was higher in the anterior group (89% vs. 73%, P = 0.03). No deaths occurred within the first 90 days after surgery, six individuals in the anterior group and three individuals in the posterior group were reoperated (P = 0.31), and five individuals in the anterior group and 24 in the posterior group suffered a wound infection (P < 0.001). CONCLUSION: Anterior surgery and posterior surgery were associated with similar neck disability and general quality of life at follow-up, whereas anterior surgery was associated with higher patient satisfaction and lower infection rates.Level of Evidence: 3.

Estimating Long-Term Vagus Nerve Stimulation Effectiveness: Accounting for Antiepileptic Drug Treatment Changes.

OBJECTIVE: To investigate the effectiveness of vagus nerve stimulation (VNS) in combination with pharmacological therapy in a longitudinal retrospective study at a single center. MATERIALS AND METHODS: Data from 130 consecutive patients implanted with a VNS device between the years 2000 and 2013 was analyzed. Seizure frequency and pharmacological antiepileptic drug (AED) treatments were recorded prior to as well as at one, two, and five years after VNS implantation. RESULTS: Median age at epilepsy onset was five years and mean years from diagnosis to VNS implantation was 16.5 years. There was a significant seizure reduction overall (all p < 0.001). The responder (≥50% seizure frequency reduction) rate increased from 22.1 to 43.8% between the first and fifth year for the cohort as a whole, with the largest increase between the first and second year (22.1-38.1%) and regardless of AED changes. VNS effectiveness did not differ between patients who altered or remained on the same AEDs. Patients were treated with a median of three AEDs throughout the study and the number of AEDs significantly increased after two (p = 0.007) and five (p = 0.001) years. CONCLUSIONS: VNS is a well-tolerated palliative neuromodulatory treatment for drug resistant epilepsy with a 43.8% seizure reduction after five years. Our data supports the idea that VNS effectiveness increases with time. Therefore we suggest that VNS should be evaluated for at least two years after implantation. AED changes should try to be kept to a minimum during evaluation in order to determine the effectiveness of VNS.

Vagal Blocking for Obesity Control: a Possible Mechanism-Of-Action.

BACKGROUND: Recently, the US FDA has approved "vagal blocking therapy or vBLoc® therapy" as a new treatment for obesity. The aim of the present study was to study the mechanism-of-action of "VBLOC" in rat models. METHODS: Rats were implanted with VBLOC, an intra-abdominal electrical device with leads placed around gastric vagal trunks through an abdominal incision and controlled by wireless device. Body weight, food intake, hunger/satiety, and metabolic parameters were monitored by a comprehensive laboratory animal monitoring system. Brain-gut responses were analyzed physiologically. RESULTS: VBLOC reduced body weight and food intake, which was associated with increased satiety but not with decreased hunger. Brain activities in response to VBLOC included increased gene expression of leptin and CCKb receptors, interleukin-1ß, tumor necrosis factor, and transforming growth factor ß1 in the brainstem; increased CCK, somatostatin, and tyrosine hydroxylase in the hippocampus; increased NPY, AgRP, and Foxa2 in the hypothalamus; and reduced CCKb receptor, melanocortin 4 receptor, and insulin receptor in the hypothalamus. Plasma concentrations of CCK, gastrin, glucagon, GLP-1, and PYY and gastric acid secretion were unchanged in response to VBLOC. CONCLUSIONS: Based on the present study, we may suggest that VBLOC induces satiety through vagal signaling, leading to reduced food intake and loss of body weight.

Complications and safety of vagus nerve stimulation: 25 years of experience at a single center.

OBJECTIVE The goal of this paper was to investigate surgical and hardware complications in a longitudinal retrospective study. METHODS The authors of this registry study analyzed the surgical and hardware complications in 247 patients who underwent the implantation of a vagus nerve stimulation (VNS) device between 1990 and 2014. The mean follow-up time was 12 years. RESULTS In total, 497 procedures were performed for 247 primary VNS implantations. Complications related to surgery occurred in 8.6% of all implantation procedures that were performed. The respective rate for hardware complications was 3.7%. Surgical complications included postoperative hematoma in 1.9%, infection in 2.6%, vocal cord palsy in 1.4%, lower facial weakness in 0.2%, pain and sensory-related complications in 1.4%, aseptic reaction in 0.2%, cable discomfort in 0.2%, surgical cable break in 0.2%, oversized stimulator pocket in 0.2%, and battery displacement in 0.2% of patients. Hardware-related complications included lead fracture/malfunction in 3.0%, spontaneous VNS turn-on in 0.2%, and lead disconnection in 0.2% of patients. CONCLUSIONS VNS implantation is a relatively safe procedure, but it still involves certain risks. The most common complications are postoperative hematoma, infection, and vocal cord palsy. Although their occurrence rates are rather low at about 2%, these complications may cause major suffering and even be life threatening. To reduce complications, it is important to have a long-term perspective. The 25 years of follow-up of this study is of great strength considering that VNS can be a life-long treatment for many patients. Thus, it is important to include repeated surgeries such as battery and lead replacements, given that complications also may occur with these surgeries.

Effects of vagus nerve stimulation on rat hippocampal progenitor proliferation.

Vagus nerve stimulation (VNS), used in the treatment of epilepsy, was approved recently for treatment-resistant depression. The mechanisms of action of the VNS anti-depressive effects are not yet fully elucidated. Modulation of hippocampal neurogenesis has been proposed as an important factor in depression pathogenesis. We evaluated the effects of VNS on hippocampal progenitor turnover in the adult rat brain. Rats receiving VNS at the output current of 0.75 mA VNS for 2 days showed a significant 50% increase in dentate gyrus BrdU-incorporation consistent with an increase in progenitor proliferation. Output currents of 0.5 or 1.5 mA yielded non-significant trends for increased BrdU-labeling indicating an inverted U-shaped proliferative dose response to VNS as previously reported for other VNS-induced effects. Specific analysis for progenitor survival revealed no effects by VNS on dentate gyrus BrdU-labeling. These results suggest that VNS induced an increase in the number of available progenitor cells in the adult rat dentate gyrus by a mechanism presumably involving increased progenitor proliferation.