Comparison of Postoperative Seizures Between Burr-Hole Evacuation and Craniotomy in Patients With Nonacute Subdural Hematomas: A Bi-Institutional Propensity Score-Matched Analysis.

BACKGROUND AND OBJECTIVES: Postoperative seizures are a common complication after surgical drainage of nonacute chronic subdural hematomas (SDHs). The literature increasingly supports the use of prophylactic antiepileptic drugs for craniotomy, a procedure that is often associated with larger collections and worse clinical status at admission. This study aimed to compare the incidence of postoperative seizures in patients treated with burr-hole drainage and those treated with craniotomy through propensity score matching (PSM). METHODS: A retrospective cohort analysis was conducted on patients with surgical drainage of nonacute SDHs (burr-holes and craniotomies) between January 2017 to December 2021 at 2 academic institutions in the United States. PSM was performed by controlling for age, subdural thickness, subacute component, and preoperative Glasgow Coma Scale. Seizure rates and accompanying abnormalities on electroencephalographic tracing were evaluated postmatching. RESULTS: A total of 467 patients with 510 nonacute SDHs underwent 474 procedures, with 242 burr-hole evacuations (51.0%) and 232 craniotomies (49.0%). PSM resulted in 62 matched pairs. After matching, univariate analysis revealed that burr-hole evacuations exhibited lower rates of seizures (1.6% vs 11.3%; P = .03) and abnormal electroencephalographic findings (0.0% vs 4.8%; P = .03) compared with craniotomies. No significant differences were observed in postoperative Glasgow Coma Scale (P = .77) and length of hospital stay (P = .61). CONCLUSION: Burr-hole evacuation demonstrated significantly lower seizure rates than craniotomy using a propensity score-matched analysis controlling for significant variables.

An analysis of potentially avoidable neurosurgical transfers to a tertiary-care level I trauma center.

OBJECTIVE: Previous studies of neurosurgical transfers indicate that substantial numbers of patients may not need to be transferred, suggesting an opportunity to provide more patient-centered care by treating patients in their communities, while probably saving thousands of dollars in transport and duplicative workup. This study of neurosurgical transfers, the largest to date, aimed to better characterize how often transfers were potentially avoidable and which patient factors might affect whether transfer is needed. METHODS: This was a retrospective cohort study of neurosurgical transfers to an urban, tertiary-care, level I trauma center between October 1, 2017, and October 1, 2022. Prior to data analysis, the authors devised criteria to differentiate necessary neurosurgical transfers from potentially avoidable ones. A transfer was considered necessary if 1) the patient went to the operating room within 12 hours of arrival at the emergency department (ED); 2) a neurological MRI study was conducted in the ED; 3) the patient was admitted to the ICU from the ED; or 4) the patient was admitted to either neurology or a surgical service (including neurosurgery). Transfers not meeting any of the above criteria were deemed potentially avoidable. Patient and clinical characteristics, including diagnostic groupings from Clinical Classification Software categories, were collected retrospectively via electronic health record data abstraction and stratified by whether the transfer was necessary or potentially avoidable. Statistical differences were assessed with a chi-square test. RESULTS: A total of 5113 neurosurgical transfers were included in the study, of which 1701 (33.3%) were classified as potentially avoidable. Four percent of all transferred patients went to the operating room within 12 hours of reaching the receiving ED, 23.4% were admitted to the ICU from the ED, 26.6% had a neurological MRI study performed in the ED, and 54.4% were admitted to a surgical service or to neurology. Potentially avoidable transfers had a higher proportion of traumatic brain injury, headache, and syncope (p < 0.0001), as well as of spondylopathies/spondyloarthropathies (p = 0.0402), whereas patients needing transfer had a higher proportion of acute hemorrhagic cerebrovascular disease and cerebral infarction (p < 0.0001). CONCLUSIONS: This study demonstrates that a large number of neurosurgical transfers can probably be treated in their home hospitals and highlights that the vast majority of patients transferred for neurosurgical conditions do not receive emergency neurosurgery. Further research is needed to better guide transferring and receiving facilities in reducing the burden of excessive transfers.

Factors Associated with Extended Hospitalization in Patients Who Had Adjuvant Middle Meningeal Artery Embolization After Conventional Surgery for Chronic Subdural Hematomas.

BACKGROUND: This study aims to evaluate the length of stay (LOS) in patients who had adjunct middle meningeal artery embolization (MMAE) for chronic subdural hematoma after conventional surgery and determine the factors influencing the LOS in this population. METHODS: A retrospective review of 107 cases with MMAE after conventional surgery between September 2018 and January 2024 was performed. Factors associated with prolonged LOS were identified through univariable and multivariable analyses. RESULTS: The median LOS for MMAE after conventional surgery was 9 days (interquartile range = 6-17), with a 3-day interval between procedures (interquartile range = 2-5). Among 107 patients, 58 stayed ≤ 9 days, while 49 stayed longer. Univariable analysis showed the interval between procedures, type of surgery, MMAE sedation, and the number of complications associated with prolonged LOS. Multivariable analysis confirmed longer intervals between procedures (odds ratio [OR] = 1.52; P < 0.01), ≥2 medical complications (OR = 13.34; P = 0.01), and neurological complications (OR = 5.28; P = 0.05) were independent factors for lengthier hospitalizations. There was a trending association between general anesthesia during MMAE and prolonged LOS (P = 0.07). Subgroup analysis revealed diabetes (OR = 5.25; P = 0.01) and ≥2 medical complications (OR = 5.21; P = 0.03) correlated with a LOS over 20 days, the 75th percentile in our cohort. CONCLUSIONS: The interval between procedures and the number of medical and neurological complications were strongly associated with prolonged LOS in patients who had adjunct MMAE after open surgery. Reducing the interval between the procedures and potentially performing both under 1 anesthetic may decrease the burden on patients and shorten their hospitalizations.

Differential Time-To-Promotion Trajectories Among Female and Male Neurosurgeons Contribute to Gender Disparities in Academic Rank Achievement.

OBJECTIVE: Despite the increasing representation of females in neurosurgical training, the fraction of female to male neurosurgeons decreases dramatically as faculty rank (Assistant, Associate, or Full Professor) increases. To assess this discrepancy, we quantified self-reported time-to-promotion trajectories for female and male neurosurgeons holding academic appointments. METHODS: In this cross-sectional institutional review board (IRB)-approved study, 147 female and 84 male neurosurgeons currently holding faculty positions in the US were contacted via email and invited to complete an anonymous, standardized survey. Respondents provided the calendar year of postgraduate training completion, promotion to different faculty ranks, geographic region of current practice (Western, Midwest, Southern, Northeast), and practice subspecialty. RESULTS: The response rate was 44.2% for females and 59.5% for males, with 114 participants included (65 female, 49 male). On average, female neurosurgeons required 25% longer to become an Associate Professor (P = 0.017), 34% longer to become a Full Professor (P = 0.004), 37% longer for promotion from Assistant to Associate Professor (P < 0.001), and 32% longer from Assistant to Full Professor (P = 0.012). Promotion timelines did not vary by region or specialty among male and female cohorts. Linear regressions revealed that female neurosurgeons with more recent training completion experienced shorter time-to-promotion to Associate and Full Professor compared to females of earlier generations (P = 0.005 and 0.001, respectively), while male timelines remained stable. CONCLUSIONS: This study identifies a significant delay in time-to-promotion for female neurosurgeons compared to their male counterparts. Investigation and standardization of promotion timelines are necessary to ensure meaningful representation gains from the increased number of women entering neurosurgical training.

Active Teaching Techniques Using Virtual Didactics: Novel Experience From a National Neurosurgery Resident Course.

OBJECTIVE: To investigate the attitudes of neurosurgery residents regarding active teaching techniques and virtual didactics based on a national neurosurgery resident sample. We also evaluated the relative cost and time commitment required for faculty participation in virtual versus in-person resident courses. DESIGN: The Society of Neurological Surgeons (SNS) national junior resident courses (JRCs) were reformatted for active teaching in a virtual setting in 2020 due to the COVID-19 pandemic. We analyzed course evaluations from the virtual 2020 courses in comparison to the 2019 in-person SNS JRCs. We also compared course budgets and agendas from these courses to identify comparative costs and the time commitment for faculty participation using these 2 course models. SETTING: Survey of nationwide participants in virtual junior resident courses. PARTICIPANTS: A total of 122 residents from 80 ACGME neurosurgery residency training programs attended the 2020 virtual JRC. RESULTS: The survey response rate of attendees was 36%. In-class engagement was thought to be good to great by 73% to 80% of the virtual learners. In-class activities and active learning techniques also were evaluated positively by 61% to 82% of respondents. Expenses were significantly lower for the virtual course, at $118 per course participant, than for the in-person course ($2722 per participant). There also was a 97.3% reduction of faculty hours and a 97.6% reduction of faculty cost for the virtual JRC compared to the in-person course. CONCLUSIONS: Neurosurgeon residents embraced the active teaching techniques used to teach portions of the prepandemic JRCs in a virtual format. Other aspects of the course curriculum could not be replicated virtually. Virtual courses were dramatically less expensive to produce, used fewer faculty teachers and required less time per faculty member. The data from this study may inform the choice of active teaching techniques for other neurosurgery residency and continuing medical education courses to optimize learner engagement and participant satisfaction in the virtual setting. We recommend that the curriculum of in-person courses emphasize hands-on, experiential learning and professional enculturation that cannot be recreated in the virtual space. Curricular elements suitable to virtual learning should take advantage of lower costs, reduced faculty time requirements, and scalability. They should also utilize active teaching techniques to improve learner engagement.

Public health insurance, frailty, and lack of home support predict rehab discharge following elective anterior cervical discectomy and fusion.

BACKGROUND CONTEXT: Anterior cervical discectomy and fusion (ACDF) is a commonly-performed and generally well-tolerated procedure used to treat cervical disc herniation. Rarely, patients require discharge to inpatient rehab, leading to inconvenience for the patient and increased healthcare expenditure for the medical system. PURPOSE: The objective of this study was to create an accurate and practical predictive model for, as well as delineate associated factors with, rehab discharge following elective ACDF. STUDY DESIGN: This was a retrospective, single-center, cohort study. PATIENT SAMPLE: Patients who underwent ACDF between 2012 and 2022 were included. Those with confounding diagnoses or who underwent concurrent, staged, or nonelective procedures were excluded. OUTCOME MEASURES: Primary outcomes for this study included measurements of accuracy for predicting rehab discharge. Secondary outcomes included associations of variables with rehab discharge. METHODS: Current Procedural Terminology codes identified patients. Charts were reviewed to obtain additional demographic and clinical characteristics on which an initial univariate analysis was performed. Two logistic regression and two machine learning models were trained and evaluated on the data using cross-validation. A multimodel logistic regression was implemented to analyze independent variable associations with rehab discharge. RESULTS: A total of 466 patients were included in the study. The logistic regression model with minimum corrected Akaike information criterion score performed best overall, with the highest values for area under the receiver operating characteristic curve (0.83), Youden's J statistic (0.71), balanced accuracy (85.7%), sensitivity (90.3%), and positive predictive value (38.5%). Rehab discharge was associated with a modified frailty index of 2 (p=.007), lack of home support (p=.002), and having Medicare or Medicaid insurance (p=.007) after correction for multiple hypotheses. CONCLUSIONS: Nonmedical social determinants of health, such as having public insurance or a lack of support at home, may play a role in rehab discharge following elective ACDF. In combination with the modified frailty index and other variables, these factors can be used to predict rehab discharge with high accuracy, improving the patient experience and reducing healthcare costs.

Prevalence and Predictors of Inappropriate Antithrombotic Prescription in Patients Presenting With Traumatic Brain Injury.

BACKGROUND AND OBJECTIVES: A growing proportion of the US population is on antithrombotic therapy (AT), most significantly within the older subpopulation. Decision to use AT is a balance between the intended benefits and known bleeding risk, especially after traumatic brain injury (TBI). Preinjury inappropriate AT offers no benefit for the patient and also increases the risk of intracranial hemorrhage and worse outcome in the setting of TBI. Our objective was to examine the prevalence and predictors of inappropriate AT among patients presenting with TBI to a Level-1 Trauma Center. METHODS: A retrospective chart review was performed on all patients with TBI and preinjury AT who presented to our institution between January 2016 and September 2020. Demographic and clinical data were collected. Appropriateness of AT was determined through established clinical guidelines. Clinical predictors were determined by logistic regression. RESULTS: Of 141 included patients, 41.8% were female (n = 59) and the average age (mean ± SD) was 80.6 ± 9.9. The prescribed antithrombotic agents included aspirin (25.5%, n = 36), clopidogrel (22.7%, n = 32), warfarin (46.8%, n = 66), dabigatran (2.1%, n = 3), rivaroxaban (Janssen) (10.6%, n = 15), and apixaban (Bristol-Myers Squibb Co.) (18.4%, n = 26). The indications for AT were atrial fibrillation (66.7%, n = 94), venous thromboembolism (13.4%, n = 19), cardiac stent (8.5%, n = 12), and myocardial infarction/residual coronary disease (11.3%, n = 16). Inappropriate antithrombotic therapy use varied significantly by antithrombotic indication ( P < .001) with the highest rates seen with venous thromboembolism. Predictive factors also include age ( P = .005) with higher rates younger than 65 years and older than 85 years and female sex ( P = .049). Race and antithrombotic agent were not significant predictors. CONCLUSION: Overall, 1 in 10 patients presenting with TBI were found to be on inappropriate AT. Our study is the first to describe this problem and warrants investigation into possible workflow interventions to prevent post-TBI continuation of inappropriate AT.

Outcome of Chronic Subdural Hematoma Intervention in Patients on Long-Term Antiplatelet Therapy-A Propensity Score Matched Analysis.

BACKGROUND: Patients presenting with chronic subdural hematomas (cSDHs) and on antiplatelet medications for various medical conditions often complicate surgical decision making. OBJECTIVE: To evaluate risks of preprocedural and postprocedural antiplatelet use in patients with cSDHs. METHODS: Patients with cSDH who were treated between January 2006 and February 2022 at a single institution with surgical intervention were identified. A propensity score matching analysis was then performed analyzing length of hospitalization, periprocedural complications, reintervention rate, rebleeding risk, and reintervention rates. RESULTS: Preintervention, 178 patients were on long-term antiplatelet medication and 298 were not on any form of antiplatelet. Sixty matched pairs were included in the propensity score analysis. Postintervention, 88 patients were resumed on antiplatelet medication, whereas 388 patients did not have resumption of antiplatelets. Fifty-five pairs of matched patients were included in the postintervention propensity score analysis. No significant differences were found in length of hospitalization (7.8 ± 4.2 vs 6.8 ± 5.4, P = .25), procedural complications (3.3% vs 6.7%, P = .68), or reintervention during the same admission (3.3% vs 5%, P = 1). No significant differences were seen in recurrence rate (9.1% vs 10.9%, P = 1) or reintervention rate after discharge (7.3% vs 9.1%, P = 1) in the postintervention group. CONCLUSION: Preintervention antiplatelet medications before cSDH treatment do not affect length of hospitalization, periprocedural complications, or reintervention. Resumption of antiplatelet medication after cSDH procedures does not increase the rebleeding risk or reintervention rate.

Effect of long-term anticoagulant therapy on the outcome of chronic subdural hematoma: a propensity score-matched analysis.

OBJECTIVE: Chronic subdural hematomas (cSDHs) are particularly common in older adults who have increased risk of falls and the conditions that require anticoagulants (ACs). In such cases, clinicians are often left with the dilemma of co-managing the cSDH and the ongoing need for ACs. METHODS: Patients who underwent surgical management for cSDH at the authors' institution between January 2006 and June 2022 were identified. Propensity score-matched analysis was used to obtain a balance in patients who were on ACs before the procedure versus those who were not, and in patients who were on ACs postprocedure versus those who were not. Length of hospitalization, periprocedural complications, reintervention rate during the same admission, rebleeding risk, and reintervention rates after discharge were compared. RESULTS: In total, 104 patients were on long-term ACs before the procedure, whereas 372 were not. After matching, 55 pairs were included in the analysis. Postprocedure, 74 patients were started on long-term ACs; the rest were not. A total of 49 patients in each group were then included in the analysis after matching. Comparing the preprocedure AC group with the non-AC group, no significant differences were found in length of hospitalization (8.5 ± 6.7 days vs 8.1 ± 7.7 days, p = 0.75), periprocedural complications (7.3% vs 7.3%, p > 0.99), or reintervention during the same admission (1.8% vs 5.5%, p = 0.31). In the comparison of postprocedure AC and non-AC groups, no significant differences were seen in recurrence rate (8.2% vs 14.3%, p = 0.52), reintervention rate after discharge (4.1% vs 14.3%, p = 0.16), or disability (i.e., mRS ≤ 2; 83.7% vs 89.8%, p = 0.55). CONCLUSIONS: Being treated with long-term ACs before cSDH procedures does not affect length of hospitalization, periprocedural complications, or reintervention during the same admission. Similarly, administration of long-term ACs after a procedure for cSDH does not increase rebleeding risk or reintervention rate. Patients who are on long-term ACs can have similar interventions to those who are not on ACs. In addition, it is safe to restart patients on AC agents in a 7- to 14-day window after admission for cSDH with or without acute/subacute components.

Reduced recurrence of chronic subdural hematomas treated with open surgery followed by middle meningeal artery embolization compared to open surgery alone: a propensity score-matched analysis.

OBJECTIVE: Middle meningeal artery embolization (MMAE) is an emerging endovascular treatment technique with proven promising results for chronic subdural hematomas (cSDHs). MMAE as an adjunct to open surgery is being utilized with the goal of preventing the recurrence of cSDH. However, the efficacy of MMAE following surgical evacuation of cSDH has not been clearly demonstrated. The authors sought to compare the outcomes of open surgery followed by MMAE versus open surgery alone. METHODS: Patients who underwent surgical evacuation alone (open surgery-alone group) or MMAE along with open surgery for cSDH (adjunctive MMAE group) were identified at the authors' institution. Two balanced groups were obtained through propensity score matching. Primary outcomes included recurrence risk and reintervention rate. Secondary outcomes included decrease in hematoma size and modified Rankin Scale (mRS) score at last follow-up. Variables in the two groups were compared by use of the Mann-Whitney U-test, paired-sample t-test, and Fisher's exact test. RESULTS: A total of 345 cases of open surgery alone and 52 cases of open surgery with adjunctive MMAE were identified. After control for subjective confounders, 146 patients treated with open surgery alone and 41 with adjunctive MMAE following open surgery with drain placement were included in the analysis. Before matching, the rebleeding risk and reintervention rate for open surgery trended higher in the open surgery alone than the open surgery plus MMAE group (14.4% vs 7.3%, p = 0.18; and 11.6% vs 4.9%, p = 0.17, respectively). No significant differences were seen in duration of radiographic or clinical follow-ups or decreases in hematoma size and mRS score at last follow-up. After one-to-one nearest neighbor propensity score matching, 26 pairs of cases were compared for outcomes. Rates of recurrence (7.7% vs 30.8%, p = 0.038) and overall reintervention (3.8% vs 23.1%, p = 0.049) after open surgery were found to be significantly lower in the adjunctive MMAE group than the open surgery-alone group. With one-to-many propensity score matching, 76 versus 37 cases were compared for open surgery alone versus adjunctive MMAE following open surgery. Similarly, the adjunctive MMAE group had significantly lower rates of recurrence (5.4% vs 19.7%, p = 0.037) and overall reintervention (2.7% vs 14.5%, p = 0.049). CONCLUSIONS: Adjunctive MMAE following open surgery can lower the recurrence risks and reintervention rates for cSDH.

Rationale and Methods for Updated Guidelines for the Management of Penetrating Traumatic Brain Injury.

Penetrating traumatic brain injury (pTBI) affects civilian and military populations resulting in significant morbidity, mortality, and healthcare costs. No up-to-date and evidence-based guidelines exist to assist modern medical and surgical management of these complex injuries. A preliminary literature search revealed a need for updated guidelines, supported by the Brain Trauma Foundation. Methodologists experienced in TBI guidelines were recruited to support project development alongside two cochairs and a diverse steering committee. An expert multi-disciplinary workgroup was established and vetted to inform key clinical questions, to perform an evidence review and the development of recommendations relevant to pTBI. The methodological approach for the project was finalized. The development of up-to-date evidence- and consensus-based clinical care guidelines and algorithms for pTBI will provide critical guidance to care providers in the pre-hospital and emergent, medical, and surgical settings.

Cerebral Metastases in Appendiceal Cancer: Comprehensive Review and Report of Rare Medullary Carcinoma Histology.

Appendiceal cancer is an extremely rare malignancy, and its metastatic spread to the brain is even more unusual. We describe a 47-year-old female who presented with a rare cerebral appendiceal carcinoma metastasis, a case that is further remarkable for representing the first histologic diagnosis of primary medullary carcinoma in the appendix. Based on a comprehensive review of the English literature using PubMed, Embase, and Google Scholar, only six other cases of cerebral appendiceal metastases have been described.

Teaching through the screen: a toolbox for creating a virtual neurosurgical subinternship program.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic disrupted the landscape of traditional neurosurgical subinternships, ramifications of which persist to this day. The outright cancellation of in-person subinternships in 2020 presented not only a challenge to both applicants and programs, but also an opportunity to establish an effective and efficient platform for virtual neurosurgical training. To address this need, the authors designed and trialed a novel virtual neurosurgical subinternship (Virtual Sub-I). METHODS: The weeklong, case-based Virtual Sub-I program combined flipped-classroom and active learning approaches. Students worked in small groups to discuss neurosurgical cases. Faculty and residents offered personalized mentorship sessions to participants. Surveys were used to assess students' experience with the authors' subinternship program, consistent with level 1 of the Kirkpatrick model. RESULTS: A total of 132 students applied from both international and American medical schools. The final cohort comprised 27 students, of whom 8 (30%) were female and 19 (70%) were male. Students characterized the subinternship as "interactive," "educational," and "engaging." One hundred percent of survey respondents were "very likely" to recommend the Virtual Sub-I to their peers. Faculty involved in the Virtual Sub-I stated that the program allowed them to determine the fit of participating medical students for their neurosurgery residency program, and that information gathered from the Virtual Sub-I had the potential to influence their ranking decisions. CONCLUSIONS: The Virtual Sub-I recapitulates the educational and interpersonal benefits of the traditional subinternship experience and can serve as a prototype for future virtual surgical education endeavors. Furthermore, the Virtual Sub-I presents a more equitable platform for introducing medical students across the undergraduate medical education spectrum to neurosurgical education and mentorship.

Future Directions for Global Clinical Neurosurgical Training: Challenges and Opportunities.

OBJECTIVE: Expanded access to training opportunities is necessary to address 5 million essential neurosurgical cases not performed annually, nearly all in low- and middle-income countries. To target this critical neurosurgical workforce issue and advance positive collaborations, a summit (Global Neurosurgery 2019: A Practical Symposium) was designed to assemble stakeholders in global neurosurgical clinical education to discuss innovative platforms for clinical neurosurgery fellowships. METHODS: The Global Neurosurgery Education Summit was held in November 2021, with 30 presentations from directors and trainees in existing global neurosurgical clinical fellowships. Presenters were selected based on chain referral sampling from suggestions made primarily from young neurosurgeons in low- and middle-income countries. Presentations focused on the perspectives of hosts, local champions, and trainees on clinical global neurosurgery fellowships and virtual learning resources. This conference sought to identify factors for success in overcoming barriers to improving access, equity, throughput, and quality of clinical global neurosurgery fellowships. A preconference survey was disseminated to attendees. RESULTS: Presentations included in-country training courses, twinning programs, provision of surgical laboratories and resources, existing virtual educational resources, and virtual teaching technologies, with reference to their applicability to hybrid training fellowships. Virtual learning resources developed during the coronavirus disease 2019 pandemic and high-fidelity surgical simulators were presented, some for the first time to this audience. CONCLUSIONS: The summit provided a forum for discussion of challenges and opportunities for developing a collaborative consortium capable of designing a pilot program for efficient, sustainable, accessible, and affordable clinical neurosurgery fellowship models for the future.

Moral Distress and Moral Injury Among Attending Neurosurgeons: A National Survey.

BACKGROUND: "Moral distress" describes the psychological strain a provider faces when unable to uphold professional values because of external constraints. Recurrent or intense moral distress risks moral injury, burnout, and physician attrition but has not been systematically studied among neurosurgeons. OBJECTIVE: To develop a unique instrument to test moral distress among neurosurgeons, evaluate the frequency and intensity of scenarios that may elicit moral distress and injury, and determine their impact on neurosurgical burnout and turnover. METHODS: An online survey investigating moral distress, burnout, and practice patterns was emailed to attending neurosurgeon members of the Congress of Neurological Surgeons. Moral distress was evaluated through a novel survey designed for neurosurgical practice. RESULTS: A total of 173 neurosurgeons completed the survey. Half of neurosurgeons (47.7%) reported significant moral distress within the past year. The most common cause was managing critical patients lacking a clear treatment plan; the most intense distress was pressure from patient families to perform futile surgery. Multivariable analysis identified burnout and performing ≥2 futile surgeries per year as predictors of distress (P < .001). Moral distress led 9.8% of neurosurgeons to leave a position and 26.6% to contemplate leaving. The novel moral distress survey demonstrated excellent internal consistency (Cronbach alpha = 0.89). CONCLUSION: We developed a reliable survey assessing neurosurgical moral distress. Nearly, half of neurosurgeons suffered moral distress within the past year, most intensely from external pressure to perform futile surgery. Moral distress correlated with burnout risk caused 10% of neurosurgeons to leave a position and a quarter to consider leaving.

Gender Equality in Neurosurgery and Strategic Goals Toward a More Balanced Workforce.

The Women in Neurosurgery (WINS) and the American Association of Neurological Surgeons published a white paper in 2008 setting an ambitious goal for women to comprise 20% of neurosurgery residents by 2012 and 20% of practicing neurosurgeons by 2020. Although there has been steady progress, we have fallen short of these benchmarks. We take this opportunity to look back at the accomplishments made over the past decade and provide an update on our present status. We evaluate current barriers toward progress and propose new goals, highlighting the systemic changes necessary to accomplish them. We propose the following updated recommendations to recruit and retain diverse talent into the neurosurgical workforce. (1) Neurosurgical departments and societies should provide diverse, early formal mentorship opportunities for medical students, residents, and junior faculty members. (2) Parental leave policies must be delineated, promoted, and enforced for all neurosurgeons, with greater awareness of internal discrimination and normalization of the discussion surrounding this topic. (3) We need to strive for compensation equity, with transparency in compensation mechanisms and regular assessment of compensation metrics. (4) Departments and institutions must have a zero-tolerance policy for sexual harassment and discrimination and establish a safe reporting structure. Finally, we propose attainable benchmarks toward achieving gender balance in the neurosurgical workforce, with a goal for women to comprise 30% of the entering residency class by 2030 and to comprise 30% of practicing neurosurgeons by 2038. We hope that this will guide further progress toward our future of building a balanced workforce.

Tumor-Derived Cell Culture Model for the Investigation of Meningioma Biology.

Meningioma is the most common primary central nervous system tumor. Although mostly nonmalignant, meningioma can cause serious complications by mass effect and vasogenic edema. While surgery and radiation improve outcomes, not all cases can be treated due to eloquent location. Presently no medical treatment is available to slow meningioma growth owing to incomplete understanding of the underlying pathology, which in turn is due to the lack of high-fidelity tissue culture and animal models. We propose a simple and rapid method for the establishment of meningioma tumor-derived primary cultures. These cells can be maintained in culture for a limited time in serum-free media as spheres and form adherent cultures in the presence of 4% fetal calf serum. Many of the tissue samples show expression of the lineage marker PDG2S, which is typically retained in matched cultured cells, suggesting the presence of cells of arachnoid origin. Furthermore, nonarachnoid cells including vascular endothelial cells are also present in the cultures in addition to arachnoid cells, potentially providing a more accurate tumor cell microenvironment, and thus making the model more relevant for meningioma research and high-throughput drug screening.

Middle Meningeal Artery Embolization Versus Conventional Treatment of Chronic Subdural Hematomas.

BACKGROUND: Middle meningeal artery (MMA) embolization is an emerging minimally invasive endovascular technique for chronic subdural hematoma (cSDH). Currently, limited literature exists on its safety and efficacy compared with conventional treatment (open-surgical-evacuation-only). OBJECTIVE: To compare MMA embolization to conventional treatment. METHODS: Retrospective analysis of patients with cSDHs treated with MMA embolization in a single center from 2018 to 2019 was performed. Comparisons were made with a historical conventional treatment cohort from 2006 to 2016. Propensity score matching analysis was used to assemble a balanced group of subjects. RESULTS: A total of 357 conventionally treated cSDH and 45 with MMA embolization were included. After balancing with propensity score matching, a total of 25 pairs of cSDH were analyzed. Comparing the embolization with the conventional treatment group yielded no significant differences in complications (4% vs 4%; P > .99), clinical improvement (82.6% vs 83.3%; P = .95), cSDH recurrence (4.3% vs 21.7%; P = .08), overall re-intervention rates (12% vs 24%; P = .26), modified Rankin scale >2 on last follow-up (17.4% vs 32%; P = .24), as well as mortality (0% vs 12%; P = .09). Radiographic improvement at last follow-up was significantly higher in the open surgery cohort (73.9% vs 95.6%; P = .04). However, there was a trend for lengthier last follow-up for the historical cohort (72 vs 104 d; P = .07). CONCLUSION: There was a trend for lower recurrence and mortality rates in the embolization era cohort. There were significantly higher radiological improvement rates on last follow-up in the surgical only cohort era. There were no significant differences in complications and clinical improvement.

A Scoping Review of Burnout in Neurosurgery.

BACKGROUND: Burnout is a negative workplace syndrome of emotional exhaustion, cynicism, and perceived professional inefficacy that risks the patient-provider relationship, patient care, and physician well-being. OBJECTIVE: To assimilate the neurosurgical burnout literature in order to classify burnout among domestic and international neurosurgeons and trainees, identify contributory factors, and appraise the impact of wellness programs. METHODS: A scoping review identified the available literature, which was reviewed for key factors related to burnout among neurosurgeons. Two researchers queried PubMed, Embase, Google Scholar, Cochrane, and Web of Science for articles on burnout in neurosurgery and reduced 1610 results to 32 articles. RESULTS: A total of 32 studies examined burnout in neurosurgery. A total of 26 studies examined prevalence and 8 studies detailed impact of wellness programs. All were published after 2011. Burnout prevalence was measured mostly through the Maslach Burnout Inventory (n = 21). In 4 studies, participants defined their own understanding of "burnout." Domestically, burnout prevalence was 11.2% to 67% among residents and 15% to 57% among attendings. Among trainees, poor operative experience, poor faculty relationships, and social stressors were burnout risks but not age, sex, or marital status. Among attendings, the literature identified financial or legal concerns, lack of intellectual stimulation, and poor work-life balance as risks. The impact of wellness programs on trainees is unclear but group exercises may offer the most benefit. CONCLUSION: Noticeable methodological differences in studies on trainee and attending burnout contribute to a wide range of neurosurgery burnout estimates and yield significant knowledge gaps. Environment may have greater impact on trainee burnout than demographics. Wellness programs should emphasize solidarity.