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.

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.

Infraclavicular de novo placement of a responsive neurostimulator for a patient with eloquent glioma-associated epilepsy: illustrative case.

BACKGROUND: The authors present a 50-year-old female with high-grade glioma involving the motor cortex as the cause of her drug-resistant epilepsy (DRE). Responsive neurostimulation (RNS) was chosen for epilepsy treatment. Due to concerns regarding the generator impeding the regular imaging surveillance required for treatment and monitoring of her glioma, surgeons placed the internal pulse generator (IPG) within an infraclavicular chest pocket. OBSERVATIONS: Implantation of the RNS device and IPG within the infraclavicular pocket was uneventful. However, both subdural and depth electrodes were used and connected to the IPG, and subdural electrodes are considerably shorter than depth electrodes (37 vs 44 cm). The shorter strip leads presumably generated significant tension, leading to fracture of the leads. Therefore, surgery was repeated using only depth electrodes for more length and less tension. The device has good-quality electrocorticography signals that continue to be used for device programming. The seizure burden was reduced, and quality of life improved for the patient. LESSONS: The RNS system with infraclavicular IPG placement reduced the seizure burden and improved the quality of life of a patient with glioma-associated epilepsy. Surgeons may consider the infraclavicular location as an alternative site for implantation for RNS candidates who require recurrent intracranial magnetic resonance imaging.

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.

Phrenic Nerve Dysfunction Secondary to Cervical Neuroforaminal Stenosis: A Literature Review.

BACKGROUND: Phrenic nerve dysfunction has been associated with cervical neuroforaminal stenosis in limited case reports and case-controlled studies. It is unclear if magnetic resonance imaging of the cervical spine should be included in the workup of patients with pulmonary dysfunction. A systematic review of the current literature was conducted on the topic to provide an outline of the body of knowledge and some guidance for neurosurgeons that receive these patient referrals. METHODS: A systematic literature review was conducted through the PubMed database to identify articles related to phrenic nerve dysfunction secondary to cervical stenosis. RESULTS: A total of 12 case reports were found. The median subject age was 64 years, 11 were male. Presenting symptoms included shortness of breath (n = 9), radiculopathy (n = 7), myelopathy (n = 5), reduced pulmonary function (n = 6), weakness (n = 4), and neck pain (n = 5). Ten of these patients underwent surgical intervention, all having improvements in their pulmonary and neurological symptoms at follow-up ranging from 10 days to 2 years. CONCLUSIONS: Cervical stenosis, resulting in neuroforaminal stenosis, may be related to phrenic nerve dysfunction in select patients with idiopathic diaphragmatic paralysis or pulmonary dysfunction. Surgical decompression improves pulmonary and neurological symptoms.

Craniofacial Chondromyxoid Fibromas: A Systematic Review and Analysis Based on Anatomic Locations.

BACKGROUND: Craniofacial chondromyxoid fibromas (CMFs) are a rare benign tumor of cartilaginous origin. They are commonly misdiagnosed due to the paucity of information on tumor characteristics. We performed a systematic review to characterize CMFs located in different regions of the craniofacial skeleton. METHODS: A search of the literature was executed using the search phrase "chondromyxoid fibroma" and included articles from 1990-2020. Sixty-eight articles met the inclusion criteria, with a total of 91 patients with analyzable data (22 with calvarial and 69 with sinonasal tumor locations). Descriptive analyses were performed to compare pre-selected characteristics between the 2 groups. RESULTS: Sinonasal CMF frequently presented with cranial nerve palsy and expectedly had a high rate of nasal symptoms. Calvarial tumors frequently presented with an external mass and headache. Gross total resection (GTR) was achieved in a higher proportion of cases in the calvarial group versus the sinonasal group (83.3% vs. 53.1%). Overall recurrence rate at 17.7% was higher in sinonasal CMF compared with the calvarial tumors at 8.3%. Recurrences after GTR were similar in the sinonasal and calvarial groups (9.7% vs. 9.1%). In patients who did not achieve GTR, recurrence was higher in the sinonasal compared with the calvarial group (27.6% vs. 0%). CONCLUSIONS: Craniofacial CMF in calvarial and sinonasal locations have distinct clinical characteristics and response to treatment. Sinonasal lesions tend to have higher recurrence compared to calvarial CMF. Performance of GTR is associated with decreased recurrence in all CMFs.

Early ventral surgical treatment without traction of acute traumatic subaxial cervical spine injuries.

BACKGROUND: Spinal cord decompression after cervical spinal cord injury (SCI) is the standard of care. However, there is a lack of consensus regarding the optimal management of these injuries, including the role of traction and timing of surgery. Here, we report the safety/efficacy of ventral surgery without preoperative traction for intraoperative fracture reduction following acute cervical SCI. METHODS: We prospectively collected a series of patients who sustained acute traumatic subaxial cervical (C3-7) spine fractures between 2004 and 2016. Patients underwent anterior cervical decompression and fusion within 24 h of injury without the utilization of preoperative traction. RESULTS: Thirty-six patients (27 male, 9 female), averaging 35 years of age, sustained 25 motor-vehicle accidents, 4 sports-related injuries, and 7 falls. Fracture dislocations were seen in 26 patients, whereas burst fractures were seen in 10. The majority of injuries occurred at the C4-5 (13 patients) and C5-6 (13 patients) levels. Complete SCI occurred in 10 patients, and incomplete SCI in 26 patients. All patients underwent anterior surgery only; 16 required vertebrectomy in addition to anterior cervical discectomy and fusion. Intraoperative reduction was achieved in all patients using a Cobb elevator or distraction pins without the use of preanesthesia traction. There were no intraoperative complications. Postoperatively, there were one postoperative hematoma, two wound/hardware revisions, one subsequent posterior fusion, and one reoperation anteriorly after screw pullout. The average hospital length of stay was 10.6 days (range 1-39). CONCLUSION: Early direct surgical stabilization/fusion for acute SCI because of subaxial cervical spine fractures is both safe and effective in selected cases when performed anteriorly without preoperative traction in select cases.