Women in Neurosurgery: First Neurosurgeon in Latin America and Current Mexican Leaders.

BACKGROUND: History has taught us that Mexican culture has been largely supported by women, despite gender prejudice from the society. Neurosurgery has not been the exception. Therefore, we investigated the challenges and influence of female neurosurgeons in Mexico. METHODS: We conducted a review of the literature and an analysis of the internal database of the Mexican Society of Neurological Surgery focusing on 3 topics: 1) the historical presence of women and gender inequality in Mexico; 2) the life and legacy of the woman who became the first neurosurgeon in Mexico and in Latin America; and 3) the participation of women in neurosurgery in the past 3 decades. RESULTS: In Latin America, the first woman in neurosurgery was María Cristina García-Sancho, who completed her neurosurgical training in 1951. Currently, women represent 6.2% of the total members of the Mexican Society of Neurological Surgery (MSNS). This percentage is still low, although data collected in this study suggest that it might increase in the next few years because 16.7% of Board Directors of the MSNS are women, the next elected president is a female neurosurgeon, and 14.5% of neurosurgery residents are women. CONCLUSIONS: Although a steady increase has occurred of women in neurosurgery in Mexico, there is still work to do, especially to overcome the barriers related to the old assumptions of the cultural and social roles of women.

Academic Accomplishments of Female Neurosurgeons Currently in Practice in the United States.

BACKGROUND: Women have now surpassed men in the number of medical students currently enrolled in the United States. However, in surgical subspecialties including neurosurgery, women continue to be significantly underrepresented. The objective of this study was to investigate the academic accomplishments of women in academic neurosurgery as measured by academic title, publications, and grant funding. METHODS: A list of ACGME (Accreditation Council for Graduate Medical Education) accredited neurosurgery departments was utilized and department websites were reviewed to collect data regarding female and male faculty. Scopus and National Institutes of Health (NIH) RePORTER websites were used to collect other variables. RESULTS: Women comprise 11.0% of all academic neurosurgeons. Of the 116 neurosurgery residency programs in the United States, 77% have at least 1 female faculty member. There are 172 academic female neurosurgeons in practice in the United States currently. Of academic female neurosurgeons, 61% are assistant professors, 21% are associate professors, and 18% are professors. Only 20 women hold leadership positions in their departments. Women have an average of 39.7 49.6 publications. The average h-index of academic female neurosurgeons is 12.0 11.1. Twenty-two women have or have had NIH funding with an average cumulative total grant value of $3,409,919. Having NIH funding and more publications is associated with higher academic rank and holding a leadership position. Women have significantly less funding and publications than men. CONCLUSIONS: Women represent younger faculty with expected publication and grant funding productivity. As women continue to advance into more senior positions, the trends for number of publications and grant funding is expected to increase.

Multimodal analgesia for craniotomy.

PURPOSE OF REVIEW: To explore the data for and against the use of the various components of multimodal analgesia in cranial neurosurgery. RECENT FINDINGS: Postcraniotomy pain is a challenging clinical problem in that analgesia must be accomplished without affecting neurologic function (i.e. 'losing the neurologic exam'). The traditional approach with low-dose opioids is often insufficient and can cause well recognized side effects. Newer multimodal analgesic approaches have proven beneficial in a variety of other surgical patient populations. The combined use of multiple nonopioid analgesics offers the promise of improved pain control and reduced opioid administration, while preserving the clinical neurologic exam. Specifically, acetaminophen and gabapentinoids should be considered for craniotomy patients, both preoperatively and postoperatively. The gabapentinoids have the added benefit of reduced nausea. Scalp blocks have moderate quality evidence supporting their use over incisional infiltration alone, with analgesia that extends into the postoperative period. Intraoperative dexmedetomidine reduces postoperative opioid requirements with the added benefit of reduced postcraniotomy hypertension. Methocarbamol, NSAIDs [both nonspecific cyclooxygenase (COX) 1 and 2 inhibitors and specific COX-2 inhibitors], ketamine, and intravenous lidocaine require further data regarding safety and efficacy in craniotomy patients. SUMMARY: Opioids are the mainstay for treating acute postcraniotomy pain but should be minimized. The evidence to support a multimodal approach is growing; neuroanesthesiologists and neurosurgeons should seek to incorporate multimodal analgesia into the perioperative care of craniotomy patients. Preoperative and postoperative gabapentin and acetaminophen, intraoperative dexmedetomidine, and scalp blocks over incisional infiltration have the most data for benefit, with good safety profiles. Further research is needed to define the safety, efficacy, and dosing parameters for NSAIDs including COX-2 inhibitors, methocarbamol, ketamine, and intravenous lidocaine in cranial neurosurgery.

Disparity in Leadership in Neurosurgical Societies: A Global Breakdown.

OBJECTIVE: Gender disparity in academic and organizational settings has been the topic of numerous studies and they have tried to extract its causes using H-index as the prime metric. The primary objective of our study was to assess gender disparity in leadership positions in neurosurgical societies worldwide. A second objective was to evaluate scholarly output among neurosurgeons in neurosurgical societies worldwide, utilizing H-index as a predominant metric. METHODS: The World Federation of Neurosurgeons database was used to gather details on the neurosurgical societies present worldwide. Online data present for leadership positions were extracted from each of the respective societies. Neurosurgeons holding leadership positions were arranged according to their academic and hierarchical ranks. The Scopus database was used to calculate H-index along with other bibliometric variables. RESULTS: H-index was statistically significant between both genders, with male neurosurgeons having significantly higher H-index than female neurosurgeons. A positive correlation was also found between H-index and academic ranks of neurosurgeons. However, no statistical significance was found between H-index and executive committee positions. Female neurosurgeons held 29% executive committee positions globally. CONCLUSIONS: A paucity of female neurosurgeons was seen in leadership positions in neurosurgical societies worldwide. Significant disparity present in research productivity between genders is a highlighted statistic further discussed in this study, considering variables such as H-index among others. The increase in female neurosurgeons to neurosurgical organizational echelons can be achieved by enhancing institutionalized support, setting up networking platforms, and identifying mentorship opportunities for prospective leaders.

Young Neurosurgeons Committee of the American Association of Neurological Surgeons: Training Ground for Future Leaders in Organized Neurosurgery in the United States of America.

The Young Neurosurgeons Committee, founded in 1991 by Dr. Roberto C. Heros, has been a vital component of the American Association of Neurological Surgeons. It has grown from an opportunity for young neurosurgeons to network with senior neurosurgeons to becoming the major voice of young neurosurgeons and a training ground for the future leaders of organized neurosurgery. The present report has reviewed the leadership involvement of 168 previous Young Neurosurgeons Committee members and briefly highlighted the careers of 4 of these members who have attained leadership positions in neurosurgery.

Neurosurgery in East Africa: Innovations.

In the last 10 years, considerable work has been done to promote and improve neurosurgical care in East Africa with the development of national training programs, expansion of hospitals and creation of new institutions, and the foundation of epidemiologic and cost-effectiveness research. Many of the results have been accomplished through collaboration with partners from abroad. This article is the third in a series of articles that seek to provide readers with an understanding of the development of neurosurgery in East Africa (Foundations), the challenges that arise in providing neurosurgical care in developing countries (Challenges), and an overview of traditional and novel approaches to overcoming these challenges to improve healthcare in the region (Innovations). In this article, we describe the ongoing programs active in East Africa and their current priorities, and we outline lessons learned and what is required to create self-sustained neurosurgical service.

The Growth of Neurosurgery in East Africa: Challenges.

As the second of 3 articles in this series, the aim of this article is to provide readers with an understanding of the development of neurosurgery in East Africa (foundations), the challenges that arise in providing neurosurgical care in developing countries (challenges), and an overview of traditional and novel approaches to overcoming these challenges and improving health care in the region (innovations). Recognizing the challenges that need to be addressed is the first step to implementing efficient and qualified surgery delivery systems in low- and middle-income countries. We reviewed the major challenges facing health care in East Africa and grouped them into 5 categories: 1) burden of surgical disease and workforce crisis; 2) global health view of surgery as "the neglected stepchild"; 3) need for recognizing the surgical system as an interdependent network and importance of organizational and equipment deficits; 4) lack of education in the community, failure of primary care systems, and net result of overwhelming tertiary care systems; 5) personal and professional burnout as well as brain drain of promising human resources from low- and middle-income countries in East Africa and similar regions across the world. Each major challenge was detailed and analyzed by authors who have worked or are currently working in the region, providing a personal perspective.

Guidelines: Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline for the Management of Patients With Positional Plagiocephaly: The Role of Physical Therapy.

BACKGROUND: Evidence-based guidelines are not currently available for the treatment of positional plagiocephaly and, in particular, for the use of physical therapy for treatment. OBJECTIVE: To answer the question: "does physical therapy provide effective treatment for positional plagiocephaly?" Treatment recommendations are created based on the available evidence. METHODS: The PubMed and the Cochrane Library were queried using MeSH headings and key words relevant to the objective of this systematic review. Abstracts were reviewed, after which studies meeting the inclusion criteria were selected and graded according to their quality of evidence (Classes I-III). Evidentiary tables were constructed that summarized pertinent study results, and recommendations were made based on the quality of the literature (Levels I-III). RESULTS: Three studies met criteria for inclusion. Two randomized, controlled trials (Class I and Class II) and 1 prospective study assessing plagiocephaly as a secondary outcome measure (Class III) were included. CONCLUSION: Within the limits of this systematic review, physical therapy is significantly more effective than repositioning education as a treatment for positional plagiocephaly. There is no significant difference between physical therapy and a positioning pillow as a treatment for positional plagiocephaly. However, given the American Academy of Pediatrics' recommendation against soft pillows in cribs to ensure a safe sleeping environment for infants, physical therapy must be recommended over the use of a positioning pillow. The full guidelines document can be located at https://www.cns.org/guidelines/guidelines-management-patients-positional-plagiocephaly/Chapter_4.

Guidelines: Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline on the Role of Cranial Molding Orthosis (Helmet) Therapy for Patients With Positional Plagiocephaly.

BACKGROUND: No evidence-based guidelines exist on the role of cranial-molding orthosis (helmet) therapy for patients with positional plagiocephaly. OBJECTIVE: To address the clinical question: "Does helmet therapy provide effective treatment for positional plagiocephaly?" and to make treatment recommendations based on the available evidence. METHODS: The US National Library of Medicine Medline database and the Cochrane Library were queried by using MeSH headings and key words relevant to the objective of this systematic review. Abstracts were reviewed, after which studies meeting the inclusion criteria were selected and graded according to their quality of evidence (Classes I-III). Evidentiary tables were constructed that summarized pertinent study results, and, based on the quality of the literature, recommendations were made (Levels I-III). RESULTS: Fifteen articles met criteria for inclusion into the evidence tables. There was 1 prospective randomized controlled trial (Class II), 5 prospective comparative studies (Class II), and 9 retrospective comparative studies (Class II). CONCLUSION: There is a fairly substantive body of nonrandomized evidence that demonstrates more significant and faster improvement of cranial shape in infants with positional plagiocephaly treated with a helmet in comparison with conservative therapy, especially if the deformity is severe, provided that helmet therapy is applied during the appropriate period of infancy. Specific criteria regarding the measurement and quantification of deformity and the most appropriate time window in infancy for treatment of positional plagiocephaly with a helmet remains elusive. In general, infants with a more severe presenting deformity and infants who are helmeted early in infancy tend to have more significant correction (and even normalization) of head shape. The full guidelines document can be located at https://www.cns.org/guidelines/guidelines-management-patients-positional-plagiocephaly/Chapter_5.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline for the Management of Patients With Positional Plagiocephaly: The Role of Physical Therapy.

BACKGROUND: Evidence-based guidelines are not currently available for the treatment of positional plagiocephaly and, in particular, for the use of physical therapy for treatment. OBJECTIVE: To answer the question: "does physical therapy provide effective treatment for positional plagiocephaly?" Treatment recommendations are created based on the available evidence. METHODS: The PubMed and the Cochrane Library were queried using MeSH headings and key words relevant to the objective of this systematic review. Abstracts were reviewed, after which studies meeting the inclusion criteria were selected and graded according to their quality of evidence (Classes I-III). Evidentiary tables were constructed that summarized pertinent study results, and recommendations were made based on the quality of the literature (Levels I-III). RESULTS: Three studies met criteria for inclusion. Two randomized, controlled trials (Class I and Class II) and 1 prospective study assessing plagiocephaly as a secondary outcome measure (Class III) were included. CONCLUSION: Within the limits of this systematic review, physical therapy is significantly more effective than repositioning education as a treatment for positional plagiocephaly. There is no significant difference between physical therapy and a positioning pillow as a treatment for positional plagiocephaly. However, given the American Academy of Pediatrics' recommendation against soft pillows in cribs to ensure a safe sleeping environment for infants, physical therapy must be recommended over the use of a positioning pillow. The full guidelines document can be located at https://www.cns.org/guidelines/guidelines-management-patients-positional-plagiocephaly/Chapter_4.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline on the Role of Cranial Molding Orthosis (Helmet) Therapy for Patients With Positional Plagiocephaly.

BACKGROUND: No evidence-based guidelines exist on the role of cranial-molding orthosis (helmet) therapy for patients with positional plagiocephaly. OBJECTIVE: To address the clinical question: "Does helmet therapy provide effective treatment for positional plagiocephaly?" and to make treatment recommendations based on the available evidence. METHODS: The US National Library of Medicine Medline database and the Cochrane Library were queried by using MeSH headings and key words relevant to the objective of this systematic review. Abstracts were reviewed, after which studies meeting the inclusion criteria were selected and graded according to their quality of evidence (Classes I-III). Evidentiary tables were constructed that summarized pertinent study results, and, based on the quality of the literature, recommendations were made (Levels I-III). RESULTS: Fifteen articles met criteria for inclusion into the evidence tables. There was 1 prospective randomized controlled trial (Class II), 5 prospective comparative studies (Class II), and 9 retrospective comparative studies (Class II). CONCLUSION: There is a fairly substantive body of nonrandomized evidence that demonstrates more significant and faster improvement of cranial shape in infants with positional plagiocephaly treated with a helmet in comparison with conservative therapy, especially if the deformity is severe, provided that helmet therapy is applied during the appropriate period of infancy. Specific criteria regarding the measurement and quantification of deformity and the most appropriate time window in infancy for treatment of positional plagiocephaly with a helmet remains elusive. In general, infants with a more severe presenting deformity and infants who are helmeted early in infancy tend to have more significant correction (and even normalization) of head shape. The full guidelines document can be located at https://www.cns.org/guidelines/guidelines-management-patients-positional-plagiocephaly/Chapter_5.