Neurosurgical Faculty Research Articles

History of neurosurgery at Christian Medical College, Vellore: A pioneer's tale.

The Department of Neurological Sciences at Christian Medical College (CMC), Vellore was the first department to start neurosurgical and neurological services in India. Jacob Chandy started the department in 1949 against several odds. He started a formal training program in neurosurgery in 1958, for the first time in India, and went on to qualify several neurosurgeons, who in turn pioneered neurosurgical departments all over India. After 1970, K V Mathai and Jacob Abraham guided the department through some difficult times when there was a severe shortage of personnel and no faculty in the neurology section. Through their commitment and hard work, they continued not only the neurosurgery service but also looked after patients with neurological disorders. Mathew J Chandy, son of Jacob Chandy, joined them in 1980 and introduced micro-neurosurgery and several other neurosurgical techniques. Training of residents in micro-neurosurgery began in the early 1980s. The last quarter of a century has been a period of rapid progress for neurosurgery at CMC. There has been an exponential rise in the number of surgeries, number of residents and number of publications. Research has always been an integral part of the activities of the department and several high impact articles have been published by the faculty and residents. The neurosurgical faculty at CMC has also contributed significantly to organized neurosurgery in India and internationally, with five of them serving as President of the Neurological Society of India, a society which had Jacob Chandy as its founder President. With this heritage, the neurosurgery section at CMC, Vellore is likely to continue to provide high quality ethical neurosurgical care to patients from all over India and overseas.

The academic productivity and impact of the University of Toronto Neurosurgery Program as assessed by manuscripts published and their number of citations.

Recent works have assessed academic output across neurosurgical programs using various analyses of accumulated citations as a proxy for academic activity and productivity. These assessments have emphasized North American neurosurgical training centers and have largely excluded centers outside the United States. Because of the long tradition and level of academic activity in neurosurgery at the University of Toronto, the authors sought to compare that program's publication and citation metrics with those of established programs in the US as documented in the literature. So as to not rely on historical achievements that may be of less relevance, they focused on recent works, that is, those published in the most recent complete 5-year period. The authors sought to make their data comparable to existing published data from other programs. To this end, they compiled a list of published papers by neurosurgical faculty at the University of Toronto for the period from 2009 through 2013 using the Scopus database. Individual author names were disambiguated; the total numbers of papers and citations were compiled on a yearly basis. They computed a number of indices, including the ih(5)-index (i.e., the number of citations the papers received over a 5-year period), the summed h-index of the current faculty over time, and a number of secondary measures, including the ig(5), ie(5), and i10(5)-indices. They also determined the impact of individual authors in driving the results using Gini coefficients. To address the issue of author ambiguity, which can be problematic in multicenter bibliometric analyses, they have provided a source dataset used to determine the ih(5) index for the Toronto program. The University of Toronto Neurosurgery Program had approximately 29 full-time surgically active faculty per year (not including nonneurosurgical faculty) in the 5-year period from 2009 to 2013. These faculty published a total of 1217 papers in these 5 years. The total number of citations from these papers was 13,434. The ih(5)-index at the University of Toronto was 50. On the basis of comparison with published bibliometric data of US programs, the University of Toronto ranks first in terms of number of publications, number of citations, and ih(5)-index among neurosurgical programs in North America and most likely in the world.

Five-year institutional bibliometric profiles for 103 US neurosurgical residency programs.

Various bibliometric indices based on the citations accumulated by scholarly articles, including the h-index, g-index, e-index, and Google's i10-index, may be used to evaluate academic productivity in neurological surgery. The present article provides a comprehensive assessment of recent academic publishing output from 103 US neurosurgical residency programs and investigates intradepartmental publishing equality among faculty members. Each institution was considered a single entity, with the 5-year academic yield of every neurosurgical faculty member compiled to compute the following indices: ih(5), cumulative h, ig(5), ie(5), and i10(5) (based on publications and citations from 2009 through 2013). Intradepartmental comparison of productivity among faculty members yielded Gini coefficients for publications and citations. National and regional comparisons, institutional rankings, and intradepartmental publishing equality measures are presented. The median numbers of departmental faculty, total publications and citations, ih(5), summed h, ig(5), ie(5), i10(5), and Gini coefficients for publications and citations were 13, 82, 716, 12, 144, 23, 16, 17, 0.57, and 0.71, respectively. The top 5 most academically productive neurosurgical programs based on ih(5)-index were University of California, San Francisco, University of California, Los Angeles, University of Pittsburgh, Brigham & Women's Hospital, and Johns Hopkins University. The Western US region was most academically productive and displayed greater intradepartmental publishing equality (median ih[5]-index = 18, median Ginipub = 0.56). In all regions, large departments with relative intradepartmental publishing equality tend to be the most academically productive. Multivariable logistic regression analysis identified the ih(5)-index as the only independent predictor of intradepartmental publishing equality (Ginipub ≤ 0.5 [OR 1.20, 95% CI 1.20-1.40, p = 0.03]). The ih(5)-index is a novel, simple, and intuitive metric capable of accurately comparing the recent scholarly efforts of neurosurgical programs and accurately predicting intradepartmental publication equality. The ih(5)-index is relatively insensitive to factors such as isolated highly productive and/or no longer academically active senior faculty, which tend to distort other bibliometric indices and mask the accurate identification of currently productive academic environments. Institutional ranking by ih(5)-index may provide information of use to faculty and trainee applicants, research funding institutions, program leaders, and other stakeholders.

Perceived benefits and barriers to a career in pediatric neurosurgery: a survey of neurosurgical residents

Research suggests that there may be a growing disparity between the supply of and demand for both pediatric specialists and neurosurgeons. Whether pediatric neurosurgeons are facing such a disparity is disputable, but interest in pediatric neurosurgery (PNS) has waxed and waned as evidenced by the number of applicants for PNS fellowships. The authors undertook a survey to analyze current neurosurgical residents' perceptions of both benefits and deterrents to a pediatric neurosurgical career. All residents and PNS fellows in the United States and Canada during the academic year 2008-2009 were invited to complete a Web-based survey that assessed 1) demographic and educational information about residents and their residency training, particularly as it related to training in PNS; 2) residents' exposure to mentoring opportunities from pediatric neurosurgical faculty and their plans for the future; and 3) residents' perceptions about how likely 40 various factors were to influence their decision about whether to pursue a PNS career. Four hundred ninety-six responses were obtained: 89% of the respondents were male, 63% were married, 75% were in at least their 3rd year of postgraduate training, 61% trained in a children's hospital and 29% in a children's "hospital within a hospital," and 72% were in programs having one or more dedicated PNS faculty members. The residencies of 56% of respondents offered 6-11 months of PNS training and nearly three-quarters of respondents had completed 2 months of PNS training. During medical school, 92% had been exposed to neurosurgery and 45% to PNS during a clinical rotation, but only 7% identified a PNS mentor. Nearly half (43%) are considering a PNS career, and of these, 61% are definitely or probably considering post-residency fellowship. On the other hand, 68% would prefer an enfolded fellowship during residency. Perceived strengths of PNS included working with children, developing lasting relationships, wider variety of operations, fast healing and lack of comorbidities, and altruism. Perceived significant deterrents included shunts, lower reimbursement, cross-coverage issues, higher malpractice premiums and greater legal exposure, and working with parents and pediatric health professionals. The intrinsic nature of PNS was listed as the most significant deterrent (46%) followed by financial concerns (25%), additional training (12%), longer work hours (12%), and medicolegal issues (4%). The majority felt that fellowship training and PNS certification should be recommended for surgeons treating of all but traumatic brain injuries and Chiari I malformations and performing simple shunt-related procedures, although they felt that these credentials should be required only for treating complex craniosynostosis. The nature of PNS is the most significant barrier to attracting residents, although reimbursement, cross-coverage, and legal issues are also important to residents. The authors provide several recommendations that might enhance resident perceptions of PNS and attract trainees to the specialty.

A National Fundamentals Curriculum for Neurosurgery PGY1 Residents

In July 2009, the Accreditation Council for Graduate Medical Education (ACGME) incorporated postgraduate year 1 (PGY1 intern) level training into all U.S. neurosurgery residency programs. To provide a fundamentals curriculum for all incoming neurosurgery PGY1 residents in ACGME-accredited programs, including skills, knowledge, and attitudes that promote quality, patient safety, and professionalism. The Society of Neurological Surgeons organized 6 regional "boot camp" courses for incoming neurosurgery PGY1 residents in July 2010 that consisted of 9 lectures on clinical and nonclinical competencies plus 10 procedural and 6 surgical skills stations. Resident and faculty participants were surveyed to assess knowledge and course effectiveness. A total of 186 of 197 U.S. neurosurgical PGY1 residents (94%) and 75 neurosurgical faculty from 36 of 99 programs (36%) participated in the inaugural boot camp courses. All residents and 83% of faculty participants completed course surveys. All resident and faculty respondents thought that the boot camp courses fulfilled their purpose and objectives and imparted skills and knowledge that would improve patient care. PGY1 residents' knowledge of information taught in the courses improved significantly in postcourse testing (P < .0001). Residents and faculty particularly valued simulated and other hands-on skills training. Regional organization facilitated an unprecedented degree of participation in a national fundamental skills program for entering neurosurgery residents. One hundred percent of resident and faculty respondents positively reviewed the courses. The boot camp courses may provide a model for enhanced learning, professionalism, and safety at the inception of training in other procedural specialties.

Increased rate of complications on a neurological surgery service after implementation of the Accreditation Council for Graduate Medical Education work-hour restriction

The Accreditation Council for Graduate Medical Education instituted mandatory 80-hour work-week limitations in July 2003. The work-hour restriction was met with skepticism among the academic neurosurgery community and is thought to represent a barrier to teaching, ultimately compromising patient care. The authors hypothesize that the introduction of the mandatory resident work-hour restriction corresponds with an overall increase in morbidity rate. This study compares the morbidity and mortality rates on an academic neurological surgery service before and after institution of the work-hour restriction. Complications are individually assessed at a monthly divisional conference by neurosurgical faculty and residents. A prospective database was commenced in July 2000 recording all complications, complications that were deemed to be potentially avoidable ("possibly preventable"), and complications that were deemed unavoidable. The incidence of morbidity and mortality from July 2000 to June 2003 is compared with the incidence from July 2003 to June 2006. The overall rate of morbidity and mortality increased from 103 to 114 per 1000 patients treated after institution of the work-hour restriction, although this increase was not statistically significant (χ(2)(1, N = 8546) = 2.6, p = 0.106). The morbidity rate increased from 70 to 89 per 1000 patients treated after institution of the work-hour restriction (χ(2)(1, N = 8546) = 10, p = 0.001). The overall mortality rate was diminished from 32 to 27 per 1000 patients treated after institution of the work-hour restriction (χ(2)(1, N = 8546) = 3.2, p = 0.075). Morbidities considered avoidable or possibly preventable were seen to increase from 56 to 66 per 1000 patients treated (χ(2)(1, N = 8546) = 5.7, p = 0.017). Avoidable or possibly preventable mortalities numbered 3 per 1000 patients treated, and this rate did not change after introduction of the work-hour restriction (χ(2)(1, N = 8546) = 0.08, p = 0.777). The morbidity rate on a neurological surgery service is increased after implementation of the work-hour restriction. Mortality rates remain unchanged.

The Surgical Skills Laboratory Residency Interview: An Enjoyable Alternative

The authors aimed to trial an alternative interviewing strategy by inviting residency candidates to our surgical anatomy laboratory. Interviews were coincident with surgical dissection. The authors hypothesized that residency candidates hoping to match into a surgical subspecialty might enjoy this unconventional interviewing strategy, which would mimic an operating room experience. On scheduled residency interview dates, formal, unstructured interviews were held with half of the neurosurgical faculty, and unstructured surgical skills laboratory-based interviews were held with the other half of the neurosurgical faculty. Interviews in the skills laboratory featured cases and corresponding surgical dissection guided by faculty. After the interview, the residency candidates were encouraged to complete an optional survey about their interview process. The survey results were pooled for analysis. Of 28 interviewed, 19 individuals responded to the survey. The survey respondents had favorable reviews of the all aspects of the interview process. When asked to report the most enjoyable part of the interview, all respondents listed the surgical skills laboratory. The average respondent scores for importance of the surgical skills laboratory interview (9.5 ± 1.1) compared with conventional interview with faculty (9.2 ± 1.0) or residents (9.1 ± 1.0) was not significantly different (p = 0.50, analysis of variance). The surgical skills laboratory interviews were reviewed favorably by the survey respondents. Nearly all respondents listed the surgical skills interview as the most enjoyable part of the interview experience. The authors advocate this residency interview strategy for surgical subspecialty residencies.

Initial experience with mobile computed tomogram in neurosurgery intensive care unit in a level 1 trauma center in India

Neurosurgical patients, in particular patients with severe head injury require frequent computed tomogram (CT) of the head, usually at short notice. A mobile CT may prove to be invaluable for these patients. This report reviews the initial experience with a mobile CT at tertiary trauma center. A total of 1292 head CT scans were done during 9 months study period with an average of 4.78 CT scans for day. Of the 563 patients in whom the detailed prospective data was available, 456 (81%) patients were on ventilator, 450 (80%) patients were on sedation, and 37 (6.5%) patients were on ionotropic support at the time of doing CT scan. The mean Glasgow Coma Scale score at the time of CT was 8.1 (range 3-15). The average time to do a CT scan (from time of request to transmission into picture archiving and communication system) was 12.6 min (range 7.8-47 min). Image quality was judged to be excellent by all the neurosurgical faculty in the intensive care unit. During the study period, the main CT scanner broke down four times (for variable time periods) and the mobile CT scanner could manage the load of severe head injured patients in the casualty without any problems. The mobile CT machine itself broke down 36 times and the mean response time was 12.5 h (range 1-144 h) during each breakdown point. This experience suggests that mobile CT is extremely useful in the management of patients with severe traumatic brain injury and can be recommended for any high-volume neurosurgery department in the country.

VIRTUAL REALITY IN NEUROSURGICAL EDUCATION

Mastery of the neurosurgical skill set involves many hours of supervised intraoperative training. Convergence of political, economic, and social forces has limited neurosurgical resident operative exposure. There is need to develop realistic neurosurgical simulations that reproduce the operative experience, unrestricted by time and patient safety constraints. Computer-based, virtual reality platforms offer just such a possibility. The combination of virtual reality with dynamic, three-dimensional stereoscopic visualization, and haptic feedback technologies makes realistic procedural simulation possible. Most neurosurgical procedures can be conceptualized and segmented into critical task components, which can be simulated independently or in conjunction with other modules to recreate the experience of a complex neurosurgical procedure. We use the ImmersiveTouch (ImmersiveTouch, Inc., Chicago, IL) virtual reality platform, developed at the University of Illinois at Chicago, to simulate the task of ventriculostomy catheter placement as a proof-of-concept. Computed tomographic data are used to create a virtual anatomic volume. Haptic feedback offers simulated resistance and relaxation with passage of a virtual three-dimensional ventriculostomy catheter through the brain parenchyma into the ventricle. A dynamic three-dimensional graphical interface renders changing visual perspective as the user's head moves. The simulation platform was found to have realistic visual, tactile, and handling characteristics, as assessed by neurosurgical faculty, residents, and medical students. We have developed a realistic, haptics-based virtual reality simulator for neurosurgical education. Our first module recreates a critical component of the ventriculostomy placement task. This approach to task simulation can be assembled in a modular manner to reproduce entire neurosurgical procedures.

Early Outcome after Craniofacial Resection of Malignant Tumors Performed by Junior Neurosurgical Faculty

Early Outcome after Craniofacial Resection of Malignant Tumors Performed by Junior Neurosurgical Faculty

Perspectives in Neurological Surgery

<i>Perspectives in Neurological Surgery</i>, edited by Daniel L. Barrow of the Division of Neurosurgery, Department of Surgery, at Emory University, is a new series of reviews by noted authors on a wide variety of subjects dealing with all major aspects of neurological surgery. The editorial board consists of an optimal mixture of leading senior neurosurgeons and young, up and coming, yet experienced junior neurosurgical faculty. Considering the large number of currently available neurosurgically oriented periodicals,<i>Perspectives in Neurological Surgery</i>is rather unique in its scope and perspective. To paraphrase the preface from the first issue, this periodical is neither a journal nor a book. Each hardbound issue is a combination of in-depth reviews of particular topics of contemporary interest and a variety of shorter, highly focused articles. Each issue includes a section entitled "Feature," which contains primarily comprehensive subject reviews. Other sections are "Focus on Technique," describing detailed preoperative, operative,

Intracranial removal of pituitary adenomas. An evaluation of varying degree of excision from partial to total.

✓ The effects of varying degrees of completeness of intracranial excision of benign pituitary adenomas among 64 patients operated on by members of the UCLA neurosurgical faculty and resident staff were assessed as to their influence upon tumor recurrences and operative mortality and morbidity. The recurrence “rate” was 9.4%. The operative mortality was 5.9%. There were lower mortality and recurrence rates among those patients treated by radical “total” excision techniques. It is not possible to predict in advance which patient will suffer a recurrence. Recurrence cannot be selectively predicted when tumor is left in place at the time of the first definitive operation. The authors believe that most benign pituitary adenomas can be radically excised and that neurosurgeons should not be content with decompressive procedures or partial removals.