Neurosurgical Outcomes Research Articles

The Evolving Role Of Artificial Intelligence In Neurosurgical Planning And Outcome Prediction: A MetaAnalysis

Artificial Intelligence (AI) is transforming various medical fields, including neurosurgery. This review explores the evolving role of AI in neurosurgical planning and outcome prediction, with a focus on its applications in preoperative imaging, intraoperative navigation, and postoperative outcome forecasting. A meta-analysis of recent studies shows that AI enhances precision, reduces errors, and offers personalized patient care. However, significant challenges such as interpretability and integration into clinical practice remain. This article discussescurrent developments, limitations, and future innovations in the use of AI in neurosurgery.

Cryopreserved decellularized human umbilical cord matrix allograft as duraplasty for fetoscopic prenatal spina bifida repair.

The objective of this study was to describe the technical aspects and postnatal neurosurgical outcomes of a prenatal, 3-miniport fetoscopic myelomeningocele (MMC) repair technique providing a multilayered closure using cryopreserved decellularized human umbilical cord (HUC) matrix allograft for duraplasty. The authors conducted a subanalysis of an ongoing prospective cohort study analyzing the neurosurgical outcomes of 57 of 92 consecutive patients who underwent multilayered fetoscopic surgical MMC repair using HUC matrix allograft for duraplasty at their institution from December 2016 to March 2022, including more than 24 months of postnatal follow-up. Of 92 patients who underwent fetoscopic MMC repair, 88 had duraplasty using cryopreserved HUC matrix allograft. Fifty-seven patients had at least 24 months of follow-up data. The mean gestational age at the time of surgical repair was 24.8 ± 0.7 weeks. The average operative time from skin incision to closure was 260 ± 43.4 minutes, in which 79% of this time was used for the fetoscopic portion. No patient required intraoperative emergency delivery. At birth, there were no cases of CSF leak or complete wound dehiscence. Six (11.5%) of 52 patients experienced superficial wound dehiscence, and only 2 (3.5%) required surgical revision. At 30 months, 54.8% of patients were noted to be independent ambulators, 35.5% were therapeutic ambulators, and 9.7% remained wheelchair users in this subset of patients. The rate of hydrocephalus requiring CSF diversion was 35.3%, and 84.3% of patients had complete reversal of hindbrain herniation at birth. Eight (15.7%) of 51 patients had spinal inclusion cysts noted on routine follow-up spinal imaging, but only 2 (3.9%) required surgical intervention due to radiological progression without neurological symptoms. A laparotomy-assisted, 3-miniport fetoscopic approach for prenatal MMC multilayered repair offers excellent access and visualization for an effective watertight closure. The use of HUC matrix allograft as a dural substitute was shown to be effective with a low rate of neurosurgical postnatal complications.

Impact of pre-existing dementia on neurosurgical intervention and outcomes in older patients with head injury: an analysis of a nationwide trauma registry in Japan.

Dementia is a common comorbidity in older patients with traumatic brain injury (TBI), potentially affecting their care processes and outcomes. However, the impact of pre-existing dementia on TBI remains unclear as research on TBI often excludes older adults with comorbidities. This study aimed to investigate the association between pre-existing dementia and outcomes in older patients admitted to hospitals after TBI. This observational study included patients aged ≥ 65years with TBI who were identified from the Japan Trauma Data Bank between January 1, 2019, and December 31, 2021. Associations between pre-existing dementia and outcomes were assessed using multivariable logistic regression analysis. The primary outcome was survival at discharge. Secondary outcomes were neurosurgical interventions and discharge to home. In total, 16,270 patients from 175 hospitals were analyzed. Of these, 1,750 (10.8%) had pre-existing dementia, and 13,520 (83.1%) survived to discharge. No significant association was observed between pre-existing dementia and neurosurgical interventions and survival at discharge. In contrast, pre-existing dementia was associated with a significantly lower likelihood of being discharged to home. Subgroup analysis revealed interactions between pre-existing dementia and the subgroups, showing adverse impact in relatively younger patients and those without severe head injury. Patients with pre-existing dementia had similar chances for neurosurgical intervention and survival at discharge than their counterparts without dementia. However, pre-existing dementia was associated with a significantly lower likelihood of being discharged to home, especially in relatively younger patients and those without severe head injury. Therefore, recognizing the risks within this population and taking measures to facilitate social reintegration is necessary.

Diabetes and heart disease do not affect short-term lumbar fusion outcomes accounting for other risk factors in a matched cohort analysis

ObjectivesComprehensive preoperative management involves the identification and optimization of medical comorbidities while avoiding excessive healthcare utilization. While diabetes and heart disease are major causes of morbidity that can worsen surgical outcomes, further study is needed to evaluate how well current perioperative strategies mitigate their risks. This study employs an exact matching protocol to isolate the effects of both diabetes and cardiovascular disease on spine surgery outcomes. Methods4680 consecutive patients undergoing single-level, posterior-only lumbar fusion were retrospectively enrolled. Univariate logistic regression was performed on comorbidity subgroups, then coarsened exact matching (CEM) was employed for patients with diabetes or cardiovascular disease. Patients were matched 1:1 on ten patient and procedural characteristics known to affect neurosurgical outcomes. Separate pairs of exact-matched cohorts were generated to isolate both cardiovascular disease (matched n = 192), and diabetes (matched n = 380). Primary outcomes were surgical complications; length of stay; discharge disposition (home vs. non-home); and 30- and 90-day Emergency Department (ED) visits, readmissions, reoperations, and mortality. ResultsCardiovascular disease and diabetes subgroups were not associated with short term outcomes after matching to control for confounders. Compared to univariate statistics, this method demonstrates that confounding control variables may drive outcomes more than these comorbidities themselves. ConclusionBetween otherwise exactly matched patients undergoing lumbar fusion, diabetes and cardiovascular disease posed no greater risk of short-term adverse outcomes. This suggests proper selection criteria for surgical candidates and effective current perioperative strategies to mitigate these common comorbidities. Further studies are warranted to assess and optimize the cost-effectiveness of preoperative management for patients with common comorbidities.

The Legacy of Harrington's Rod and the Evolution of Long-Segment Constructs in Spine Surgery.

This paper delves into the historical evolution of spinal surgery, focusing on the pivotal role of the Harrington rod in treating spinal deformities. Introduced in 1955, the Harrington rod marked a significant breakthrough in neurosurgery, especially for scoliosis treatment, by offering a novel approach to spinal stabilization. Through a retrospective analysis, this study examines the development and impact of the Harrington rod, highlighting Dr. Paul Harrington's contributions to spinal surgery. His innovative technique revolutionized the management of spinal deformities, laying the groundwork for future advancements in spinal instrumentation. Despite initial skepticism, Harrington's methods gained acceptance, significantly influencing neurosurgical practices and patient outcomes. This study also explores subsequent advancements that built on Harrington's work, including the transition to long-segment spine constructs and the introduction of segmental pedicle screws, which allowed for more precise deformity correction. Reflecting on Harrington's legacy, this paper acknowledges the continuous evolution of spinal surgery, driven by the interplay between clinical challenges and technological innovations. Harrington's pioneering spirit exemplifies the ongoing pursuit of better surgical outcomes, underscoring the importance of innovation in the field of neurosurgery.

The Impact of Infection Prevention Bundles on Neurosurgical Outcomes and Healthcare Costs: A Systematic Review

Background: Post-operative infections represent a significant challenge in neurosurgery, leading to increased morbidity, mortality, and healthcare costs. The implementation of infection prevention bundles, which encompass a set of evidence-based practices, has emerged as a potential solution to mitigate these adverse outcomes. This systematic review aims to evaluate the effectiveness of infection prevention bundles in improving neurosurgical outcomes and reducing healthcare costs. Methods: A comprehensive search of electronic databases (PubMed, Scopus, Web of Science) was conducted to identify studies published between 2010 and 2023 that evaluated the impact of infection prevention bundles on neurosurgical outcomes and healthcare costs. The search strategy included keywords such as "neurosurgery," "infection prevention," "surgical site infection," "bundle," "outcomes," and "healthcare costs." Studies were included if they reported on at least one clinical outcome (e.g., surgical site infection rates, mortality, length of stay) and/or healthcare costs. Data extraction and quality assessment were performed independently by two reviewers. Results: The search yielded 45 studies that met the inclusion criteria. The studies encompassed a variety of neurosurgical procedures, including craniotomies, spinal surgeries, and deep brain stimulation. The infection prevention bundles implemented varied across studies but commonly included preoperative antibiotic prophylaxis, skin antisepsis, and intraoperative measures. The pooled analysis demonstrated a significant reduction in surgical site infection rates and length of stay associated with the use of infection prevention bundles. Moreover, several studies reported cost savings, primarily attributed to reduced complications and shorter hospital stays. Conclusion: The evidence suggests that infection prevention bundles are effective in improving neurosurgical outcomes and reducing healthcare costs. The implementation of these bundles should be considered a standard of care in neurosurgery to enhance patient safety and optimize resource utilization. Keywords: Neurosurgery, infection prevention, surgical site infection, healthcare costs, systematic review.

Practical pearls for management of cranial injury in the developing world.

Traumatic brain injury (TBI) remains a leading cause of morbidity and mortality, with approximately 69million individuals affected globally each year, particularly in low- and middle-income countries (LMICs) where neurosurgical resources are limited. The neurocognitive consequences of TBI range from life-threatening conditions to more subtle impairments such as cognitive deficits, impulsivity, and behavioral changes, significantly impacting patients' reintegration into society. LMICs bear about 70% of the global trauma burden, with causes of TBI differing from high-income countries (HICs). The lack of equitable neurosurgical care in LMICs exacerbates these challenges. Improving TBI care in LMICs requires targeted resource allocation, neurotrauma registries, increased education, and multidisciplinary approaches within trauma centers. Reports from successful neurotrauma initiatives in low-resource settings provide valuable insights into safe, adaptable strategies for managing TBI when "gold standard" protocols are unfeasible. This review discusses common TBI scenarios in LMICs, highlighting key epidemiological factors, diagnostic challenges, and surgical techniques applicable to resource-limited settings. Specific cases, including epidural hematoma, subdural hematoma, subarachnoid hemorrhage, and cerebrospinal fluid leaks, are explored to provide actionable insights for improving neurosurgical outcomes in LMICs.

The impact of socioeconomic determinants on the access to care and survival in patients with spinal chordomas- a national cancer database analysis.

Chordomas are rare malignant neoplasms primarily treated surgically. Disparities related to race and socioeconomic status, may affect patient outcomes. This study aims to identify prognostic factors for access to care and survival in patients with spinal chordomas. The NCDB database was queried between the years 2004 and 2017. Kaplan-Meier curves were constructed to compare survival probabilities among different groups, based on race and socioeconomic determinents. 1769 patients were identified, with 87% being White, 5% Hispanic, 4% Black, and Asian each. The mean age was 61.3 years. Most patients received care at academic/research centers and lived in a large metropolitan area, with no difference between races. A significantly higher percentage of Black patients did not undergo surgery (p < 0.001), with no statistically significant difference in survival between races (p = 0.97). A higher survival probability was seen in patients with other government insurances (p < 0.0001), in higher income quartiles (p < 0.0001), in metropolitan areas (p = 0.023), and at an academic/research center (p < 0.0001). A lower survival probability was seen in patients who are uninsured, in rural areas, and at community cancer programs (p < 0.0001). This study highlights disparities in access to surgical intervention for patients with spinal chordomas, especially among Black individuals. It emphasizes the significant impact of insurance status and income on access to surgical care and highlights geographical and institutional variations in survival rates. Addressing socioeconomic differences is crucial for fostering equity in neurosurgical outcomes.

Social determinants of health and outcome disparities in spine tumor surgery. Part 1: An analysis of 6.6 million nationwide admissions.

Earlier research has demonstrated that social determinants of health (SDoH) impact neurosurgical access and outcomes, but these trends are less characterized for spine tumors relative to intracranial tumors. The authors aimed to elucidate the association between SDoH and outcomes for a nationwide cohort of spine tumor surgery admissions. The authors identified all admissions with a spine tumor diagnosis in the National Inpatient Sample (NIS) from 2002 to 2019. Four SDoH were analyzed: race and ethnicity, insurance, household income, and safety-net hospital (SNH) treatment. Hospitals in the top quartile of safety-net burden (in terms of percentage of patients receiving Medicaid or uninsured) were categorized as SNHs. Multivariable regression queried the association between 22 variables and 5 perioperative outcomes: mortality, discharge disposition, complications, length of stay (LOS), and hospitalization costs. Interaction term analysis with hospitalization year was used to assess longitudinal changes in outcome disparities. Finally, the authors constructed random forest machine learning models to assess the impact of SDoH variables on prognostic accuracy and to quantify the relative importance of predictors for disposition. Of 6,593,392 total admissions with spine tumors, 219,380 (3.3%) underwent surgery. Non-White race (OR 0.80-0.91, p < 0.001) and nonprivate insurance (OR 0.76-0.83, p < 0.001) were associated with lower odds of receiving surgery. Among surgical admissions, presenting severity, including of myelopathy and plegia, was elevated among non-White, nonprivate insurance, and low-income admissions (all p < 0.001). Black race (OR 0.70, p < 0.001), Medicare (OR 0.70, p < 0.001), Medicaid (OR 0.90, p < 0.001), and lower income (OR 0.88-0.93, all p < 0.001) were associated with decreased odds of favorable discharge disposition. Increased LOS and costs were observed among non-White (+6%-10% in LOS and +5%-9% in costs, both p < 0.001) and Medicaid (+16% in LOS and +6% in costs, both p < 0.001) admissions. SNH treatment was also associated with higher mortality (OR 1.49, p < 0.001) and complication (OR 1.20, p < 0.001) rates. From 2002 to 2019, disposition improved annually for Medicaid patients (OR 1.03 per year, p = 0.022) but worsened for Black patients (OR 0.98 per year, p = 0.046). Random forest models identified household income as the most important predictor of discharge disposition. For spine tumor admissions, SDoH predicted surgical intervention, presenting severity, and perioperative outcomes. Over 2 decades, disparities improved for Medicaid patients but worsened for Black patients. Finally, SDoH significantly improve prognostic accuracy for outcomes after spine tumor surgery. Further study toward ameliorating patient disparities for this population is warranted.

The effect of chronic kidney disease on short-term single-level lumbar fusion outcomes

IntroductionChronic kidney disease (CKD) has an increasing global prevalence and has previously been associated with increased complications and morbidity after spine surgery. Understanding the isolated effect of CKD on short-term patient outcomes is critical for optimizing perioperative risk management and healthcare utilization. ObjectiveThe aim of this study is to utilize coarsened exact matching (CEM) to analyze the isolated effect of CKD on short-term patient outcomes in single-level posterior lumbar fusion surgery. MethodsA retrospective analysis of 4680 consecutive patients undergoing single-level, posterior-only lumbar fusion was performed. Univariate logistic regression comparing the odds of outcomes in patients with CKD (n=40) to patients without medical comorbidities (n=2329) was performed. CEM was then employed to match patients with CKD to those without any comorbidities 1:1 on ten patient characteristics known to affect neurosurgical outcomes. Primary outcomes included intraoperative complications, length of stay, discharge disposition, and 30-day Emergency Department (ED) visits, readmissions, reoperations, and mortality. ResultsIn a univariate logistic regression, CKD was associated with increased risk of 30-day ED visits (OR=3.53, p=0.003) but not complication, discharge disposition, or 30-day readmissions or reoperations. Between otherwise exactly matched patients (n=72), CKD similarly remained associated with an increased risk of 30-day ED visits (OR=7.00, p=0.034) and not with other outcomes. ConclusionBetween otherwise exactly matched patients undergoing single-level posterior lumbar fusion, CKD was related to increased risk of 30-day ED utilization but not other markers indicative of inferior surgical outcomes. Further study must investigate the reasons for increased ED visitation and implement risk-mitigation strategies for these patients.

Prognostic efficiency of diagnostic blockade as a method of modeling the result of selective neurotomy of the motor branches of the median nerve in patients with cerebral palsy

BACKGROUND: A feature of the disease course in patients with spastic cerebral palsy is a combination of motor neurological disorders with contractures in extremity joints. Neurosurgical methods are currently the main treatment for correcting the pathological tone of the “spastic hand.” However, the decreased tone does not affect secondary (fixed) contractures; therefore, the effectiveness of this type of treatment is extremely dependent on the accurate selection of a certain category of patients. Presumably, diagnostic blockade of the median nerve can create a reversible model for planned neurosurgical treatment. The inclusion of this technique as a standard for examining a patient with spastic cerebral palsy before invasive tone-lowering treatment can radically promote treatment effectiveness. AIM: This study aimed to assess the prognostic effectiveness of diagnostic blockade as a method of modeling the result of selective neurotomy of the motor branches of the median nerve in patients with cerebral palsy. MATERIALS AND METHODS: A longitudinal prospective study enrolled 39 children (aged 5–18 years) with spastic cerebral palsy. Before neurosurgical treatment, each patient underwent a diagnostic n. medianus under electrical stimulation and ultrasound control. After a diagnostic blockade, only patients who had a good functional and goniometric response were selected for the study, which served as an indication for selective neurotomy of the median nerve, and orthopedic treatment was performed in children with a negative event. Patients referred for neurotomy underwent a standardized examination before treatment during the diagnostic blockade and after neurosurgical treatment. The examination included the assessment of the amplitude of passive and active movements in the joints of the upper extremities, muscle tone, and functional capabilities of the upper extremities and dynamometry. RESULTS: In comparison with the initial data, a significant increase in the amplitude of passive and active hand extension, passive and active abduction of the first finger, and upper limb functional capabilities according to the MACS classification and the Miller scale was determined both after the diagnostic blockade and after selective neurotomy of the motor branches of the median nerve. CONCLUSIONS: Based on the results of the study, the effect of the diagnostic blockade and neurosurgical treatment outcomes are unidirectional, which allows the use of blockade as a method for modeling the possible result in clinically complex cases of spastic hand. The use of diagnostic blockade in clinical practice makes it possible to adequately assess the severity of fixed contractures and reduce the pathological hypertonicity of the target muscles. Diagnostic blockade allows for the collection of sufficient information to make an objective decision about which type of treatment is most preferable for each patient – neurosurgical, orthopedic, or sequential use of both methods.

Single Center Neurosurgical Outcomes and Trends in Endoscopic Endonasal Resection of 297 Sellar/Suprasellar Tumors Stratified by Duration of Neurosurgical Career

Endoscopic endonasal transsphenoidal surgery (EETS) is a common treatment for sellar and suprasellar tumors. While endoscopic training has improved over the years and formal fellowship training is now broadly available, the operative nuances of EETS conjectures the existence a learning curve as a neurosurgeon matures with experience. We aim to evaluate operative outcomes of three different experience levels of neurosurgeons over time at a single institution. We reviewed all adult patients who underwent EETS at Loyola University Medical Center by three early career, one mid-career, and two late career neurosurgeons from 2007 to 2023. A comparative assessment of patient demographics, tumor features, and surgical outcomes was done using metrics such as length of surgery, rates of gross total resection (GTR) and symptomatic improvement (SI), new postoperative steroid dependence, and development of diabetes insipidus (DI). T-tests and Chi-Square were used to statistically evaluate the study cohorts. A total of 297 patients underwent EETS. One hundred and three (35%) were operated on by an early career, 122 (41%) by a mid-career, and 72 (24%) by a late career neurosurgeon. Late-career surgeons had shorter operation times (144 vs. 180 minutes with early and mid-career, p=0.029) and increased GTR rates (p=0.008). There were no significant differences between the SI rates amongst various surgeon experience levels. Although not statistically significant, early-career neurosurgeons had lower rates of new postoperative steroid dependence. Patients of early career surgeons experienced significantly less DI (15% vs 40%, p=0.004). Late-career neurosurgeons had shorter operation lengths, achieved higher rates of GTR, and their patients experienced significantly higher rates of DI. Overall outcomes remained stable throughout the course of 16 years between different surgeon experience levels.

Risk Analysis Index Predicts Nonhome Discharge Following Resection of Cavernous Malformations

Intracranial cavernous malformations (CMs) are benign vascular lesions associated with hemorrhage, seizures, and corresponding neurological deficits. Recent evidence shows that frailty predicts neurosurgical adverse outcomes with superior discrimination compared to greater patient age. Therefore, we utilized the Risk Analysis Index (RAI) to predict adverse outcomes following cavernous malformation resection (CMR). This retrospective study utilized the Nationwide Inpatient Sample to identify patients who underwent craniotomy for CMR (2019-2020). Multivariate analysis used RAI to assess the ability of frailty to predict nonhome discharge (NHD), extended length of stay (eLOS), and postoperative adverse outcomes. Receiver operating characteristic curve analysis evaluated the discriminatory accuracy of RAI for prediction of NHD. One thousand two hundred CMR patients were identified. Mean patient age was 38±1.2years, 53.3% (N=640) were female, and 58.3% (N=700) had private insurance. Patients were stratified into 4 frailty tiers based on RAI scores: "robust" (0-20, R), N=905 (80.8%); "normal" (21-30, N), N=110 (9.8%); "frail" (31-40, F), N=25 (2.2%); and "very frail" (41+, VF), N= 80 (7.1%). Increasing frailty was associated with eLOS and higher rates of NHD (P<0.05). The RAI demonstrated strong discriminatory accuracy (C-statistic=0.722) for prediction of NHD following CMR in area under the receiver operating characteristics. Preoperative frailty independently predicts adverse outcomes, including eLOS and NHD in patients undergoing resection of cranial CMs. Integrating RAI into preoperative frailty risk assessment may optimize risk stratification and improve patient selection and reallocate perioperative management resources for better patient outcomes.

Neurosurgical short-term outcomes for pediatric medulloblastoma patients and molecular correlations: a 10-year single-center observation cohort study.

This study examined the risk factors for short-term outcomes, focusing particularly on the associations among molecular subgroups. The analysis focused on the data of pediatric patients with medulloblastoma between 2013 and 2023, as well as operative complications, length of stay from surgery to adjuvant treatment, 30-day unplanned reoperation, unplanned readmission, and mortality. 148 patients were included. Patients with the SHH TP53-wildtype exhibited a lower incidence of complications (45.2% vs. 66.0%, odds ratio [OR] 0.358, 95% confidence interval [CI] 0.160 - 0.802). Female sex (0.437, 0.207 - 0.919) was identified as an independent protective factor for complications, and brainstem involvement (1.900, 1.297 - 2.784) was identified as a risk factor. Surgical time was associated with an increased risk of complications (1.004, 1.001 - 1.008), duration of hospitalization (1.006, 1.003 - 1.010), and reoperation (1.003, 1.001 - 1.006). Age was found to be a predictor of improved outcomes, as each additional year was associated with a 14.1% decrease in the likelihood of experiencing a prolonged length of stay (0.859, 0.772 - 0.956). Patients without metastasis exhibited a reduced risk of reoperation (0.322, 0.133 - 0.784) and readmission (0.208, 0.074 - 0.581). There is a significant degree of variability in the occurrence of operative complications in pediatric patients with medulloblastoma. SHH TP53-wildtype medulloblastoma is commonly correlated with a decreased incidence of complications. The short-term outcomes of patients are influenced by various unmodifiable endogenous factors. These findings could enhance the knowledge of onconeurosurgeons and alleviate the challenges associated with patient/parent education through personalized risk communication. However, the importance of a dedicated center with expertise surgical team and experienced neurosurgeon in improving neurosurgical outcomes appears self-evident.

Sub-Saharan African experience of neurosurgical oncology care: challenges and barriers encountered at 7 cancer treatment centers

OBJECTIVE Wide disparities in neurosurgical oncology care and treatment outcomes exist globally despite recent improvements in diagnostics and cancer therapy. To better understand the challenges to neurosurgical oncology care in low-resource settings, the authors collected data on national neurosurgical capacity and hospital diagnostic and treatment capacity across 7 national referral hospitals in 7 countries in sub-Saharan Africa (SSA). METHODS In April 2023, a 42-item self-administered questionnaire was distributed to partner neurosurgeons at the 7 centers via REDCap to provide country- and hospital-level capacity data on neurosurgical oncology care. RESULTS Neurosurgical and neurosurgical oncology care were reported to be available in a limited number of provinces, states, regions, and counties in 6 of the 7 countries. The general neurosurgical workforce density across the 7 countries ranged from 0.03 to 0.67 per 100,000 persons, and that of the pediatric neurosurgical workforce ranged from 0 to 0.05 per 100,000 persons. Two centers had no pediatric ICUs, and the remaining 5 centers had pediatric ICUs with bed capacities between 1 and 8. One hospital had neither a CT nor an MRI scanner available and relied solely on private diagnostic facilities for neuroimaging. Histopathology services were largely limited to basic histopathology staining only; molecular subtyping was available at a single center. Three hospitals offered pediatric anesthesia expertise. None of the hospitals offered subspecialty neuro-oncology care or had a pediatric neuro-oncologist. None of the 7 hospitals had formal neurocritical care, neuroradiology, or neuropathology expertise. Neither adjuvant chemotherapy nor radiotherapy was available at 3 centers. Rehabilitation was largely limited to basic physical and occupational therapy at all 7 centers. Although all 7 countries had a multiple health payer system, the payment structure differed across the 7 hospitals for different neurosurgical oncology services, with patients making out-of-pocket payments for all services in some cases. CONCLUSIONS There are significant challenges to timely and quality neurosurgical oncology care in SSA especially for children. System-level interventions are needed to strengthen neurosurgical oncology care capacity in SSA.

Stereotactic Radiosurgery for Ependymoma in Pediatric and Adult Patients: A Single-Institution Experience.

Ependymoma is commonly classified as World Health Organization grade 2 with the anaplastic variant categorized as grade 3. Incomplete resection or anaplastic features can result in unfavorable outcomes. Stereotactic radiosurgery (SRS) provides a minimally invasive approach for recurrent ependymomas. Our study investigates the efficacy and safety of SRS for grade 2 and 3 ependymomas in pediatric and adult populations. We conducted a retrospective analysis on 34 patients with 75 ependymomas after CyberKnife SRS between 1998 and 2023. Fourteen were pediatric (3-18 years), and 20 were adult (19-75 years) patients. The median age was 21 years, and the median tumor volume was 0.64 cc. The median single-fraction equivalent dose was 16.6 Gy, with SRS administered at 77% of the median isodose line. After a median follow-up of 42.7 months (range: 3.8-438.3), 22.7% of ependymomas progressed. The 5-year local tumor control rate was 78.1%, varying between 59.6% and 90.2% for children and adults, with grade 2 at 85.9% compared with 58.5% for grade 3 tumors. The 5-year overall survival rate was 73.6%, notably higher in adults (94.7%) than in children (41%), and 100% for grade 2 but decreased to 35.9% for grade 3 patients. The 5-year progression-free survival rate was 68.5%, with 78.3% and 49.2% for adults and children, respectively, and a favorable 88.8% for grade 2, contrasting with 32.6% for grade 3 patients. Symptom improvement was observed in 85.3% of patients. Adverse radiation effects occurred in 21.4% of pediatric patients. Our study supports SRS as a viable modality for pediatric and adult patients with grade 2 and 3 ependymomas. Despite lower local tumor control in pediatric and grade 3 cases, integrating SRS holds promise for improved outcomes. Emphasizing careful patient selection, personalized treatment planning, and long-term follow-up is crucial for optimal neurosurgical outcomes.

Patterns and short term neurosurgical treatment outcomes of neonates with neural tube defects admitted to Felege Hiwot Specialized Hospital, Bahir Dar, Ethiopia

BackgroundNeural tube defects (NTDs) account for the largest proportion of congenital anomalies of the central nervous system and result from failure of the neural tube to close spontaneously between the 3rd and 4th weeks of in utero development. Prognosis and treatment outcome depends on the nature and the pattern of the defect. The nature of treatment outcomes and its pattern associated with grave prognosis is not well known in the study area.ObjectiveThe aim of study was to determine the patterns and short term neurosurgical management outcomes of newborns with neural tube defects admitted at Felege Hiwot Specialized Hospital.MethodsInstitutional based retrospective cross-sectional study among neonates, who were admitted at Felege Hiwot Specialized Hospital with neural tube defects from January 1st to December, 30th, 2018 was conducted. All Charts of Neonates with confirmed diagnosis of neural tube defects were included as part of the study. Trained data collectors (medical interns) supervised by trained supervisors (general practitioners) collected the data using a pretested data extraction format. Data were coded, entered and analyzed using SPSS version 23 software. Frequency and cross tabulations were used to summarize descriptive statistics of data, and tables and graphs were used for data presentation.ResultAbout 109 patients had complete documentation and imaging confirmed neural tube defects. Myelomeningocele was the commonest pattern 70 (64.2%). Thoracolumbar spine was the commonest site of presentation 49(45%). The most common associated impairment was hydrocephalus 37(33.9%). Forty-five (41.1%) had multiple complications. The mortality rate was 7.3%, 44% were discharged with sequalae and 36.7% were discharged without impairment. The significant causes of death were infection 66.7% and Chiari crisis 33.3%.ConclusionMyelomeningocele was the most frequent clinical pattern of neural tube defect and thoracolumbar spine was the commonest site. Isolated neural tube defect was the commonest finding. There were multiple complications after surgery accompanied with meningitis and hydrocephalus. The mortality rate among neonates with neural tube defects was considerably high. The commonest causes of death were infection and Chiari crisis.

Apert syndrome: neurosurgical outcomes and complications following posterior vault distraction osteogenesis.

Posterior vault distraction osteogenesis (PVDO) has been utilized during the past 15 years to treat a variety of clinical features commonly presented by patients with Apert syndrome. The objective of this study is to determine the efficacy of PVDO in addressing both elevated intracranial pressure (ICP) and ectopia of the cerebellar tonsils (ECT) in young Apert patients. In addition, we aimed to determine the prevalence of hydrocephalus in Apert syndrome patients who underwent PVDO. A retrospective study was made with a cohort of 40 consecutive patients with syndromic craniosynostosis (SC), previously diagnosed with Apert syndrome, who underwent PVDO between 2012 and 2022, and thereafter received at least 1 year of follow-up care. Demographic data and diagnosis, along with surgical and outcome data, were verified using medical records, clinical photographs, radiologic examination, and interviews with the parents of all cohort patients. The average patient age when PVDO was performed was 12.91 ± 10 months. The average posterior advancement distance achieved per patient was 22.68 ± 5.26mm. The average hospital stay per patient was 3.56 ± 2.44 days. The average absolute and relative blood transfusion volumes were 98.47ml and 17.63ml/kg, respectively. Although five patients (14%) presented ECT preoperatively, this condition was completely resolved by PVDO in three of these five patients. One of the three patients whose ECT had completely resolved presented syringomyelia postoperatively, requiring subsequent extra dural foramen magnum decompression. All of the remaining four patients were asymptomatic for ECT for at least 1 year of follow-up, and none of these four patients required any additional treatments to address ECT. Two patients presented hydrocephalus requiring ventriculoperitoneal shunt placement. This study demonstrates that PVDO both reduces diagnosed elevated ICP symptoms and is partially effective in treating ECT in Apert syndrome patients. Hydrocephalus in Apert syndrome is an uncommon feature. The effectiveness of PVDO in addressing hydrocephalus is uncertain.

Effect of neurosurgical residency programs on neurosurgical patient outcomes in a single health care system: a cohort study.

The evidence on the benefits and drawbacks of involving neurosurgical residents in the care of patients who undergo neurosurgical procedures is heterogeneous. We assessed the effect of neurosurgical residency programs on the outcomes of such patients in a large single-payer public health care system. Ten population-based cohorts of adult patients in Ontario who received neurosurgical care from 2013 to 2017 were identified on the basis of procedural codes, and the cohorts were followed in administrative health data sources. Patient outcomes by the status of the treating hospital (with or without a neurosurgical residency program) within each cohort were compared with models adjusted for a priori confounders and with adjusted multilevel models (MLMs) to also account for hospital-level factors. A total of 46 608 neurosurgical procedures were included. Operative time was 8%-30% longer in hospitals with neurosurgical residency programs in 9 out of 10 cohorts. Thirty-day mortality was lower in hospitals with neurosurgical residency programs for aneurysm repair (odds ratio [OR] 0.30, 95% confidence interval [CI] 0.20-0.44), cerebrospinal fluid shunting (OR 0.52, 95% CI 0.34-0.79), intracerebral hemorrhage evacuation (OR 0.66, 95% CI 0.52-0.84), and posterior lumbar decompression (OR 0.32, 95% CI 0.15-0.65) in adjusted models. The mortality rates remained significantly different only for aneurysm repair (OR 0.19, 95% CI 0.05-0.69) and cerebrospinal shunting (OR 0.42, 95% CI 0.21-0.85) in MLMs. Length of stay was mostly shorter in hospitals with neurosurgical residents, but this finding did not persist in MLMs. Thirty-day reoperation rates did not differ between hospital types in MLMs. For 30-day readmission rates, only extracerebral hematoma decompression was significant in MLMs (OR 1.41, 95% CI 1.07-1.87). Hospitals with neurosurgical residents had longer operative times with similar to better outcomes. Most, but not all, of the differences between hospitals with and without residency programs were explained by hospital-level variables rather than direct effects of residents.

Assessing pediatric neurosurgery capacity in La Paz, Bolivia: an illustrative institutional experience of a lower-middle-income country in South America.

The current pediatric neurosurgery capacity in lower-middle-income countries (LMICs) in South America is poorly understood. Correspondingly, the authors sought to interrogate the neurosurgical inpatient experience of the sole publicly funded pediatric hospital in one of the largest regional departments of Bolivia to better understand this capacity. A retrospective review of all neurosurgical procedures performed at the Children's Hospital of La Paz, Bolivia (Hospital del Niño "Dr. Ovidio Aliaga Uria") between 2019 and 2023 was conducted after institutional approval using a recently implemented national electronic medical record system. A total of 475 neurosurgical admissions satisfied inclusion for analysis over the 5-year span. The majority of admissions were from within the La Paz Department (87%) via the emergency department (77%), without private insurance (83%). The most common indications for neurosurgical intervention were trauma (35%), followed by hydrocephalus (28%), congenital disease (12%), infection (5%), and craniosynostosis (3%). Overall, the median age at time of surgery was 2.0 years, and the median operating time was 1.5 hours with a minority of intraoperative complications (2%). The most common inpatient complication was unplanned return to the operating room (19%), most commonly seen in congenital indications. At final discharge, the median postoperative length of stay was 10 days. Twenty-seven (6%) of the 475 patients died during hospitalization, most commonly seen in tumor indications. Of the 448 patients who were discharged, 299 (67%) returned for at least one follow-up appointment. There is restricted breadth in neurosurgical indications and outcomes achievable at the Children's Hospital of La Paz, Bolivia. As such, the capacity of pediatric neurosurgery at institutions in LMICs in South America such as this one is very limited. Identifying and prioritizing actionable interventions to improve this capacity is institution- and LMIC-dependent, and as such, future efforts will need to be tailored appropriately.