Neurosurgical Subspecialties Research Articles

Antidepressant Prescriptions in Neurosurgical Practice: A Survey of Current Trends.

To better understand the indications and the impact of antidepressant drugs on the field of neurosurgery in terms of risks and benefits in Turkey. A national survey was conducted among neurosurgeons in current practice in Turkey to report routine prescription trends of antidepressant drugs. Gender, neurosurgical subspecialty, city, type of practice, years of experience, antidepressant agent, indications and reasons not to prescribe were ascertained. A brief review of literature was done to show clinical and research evidence. A total of 336 neurosurgeons took the survey; 53% of them prescribe antidepressants routinely, whereas 47% of them do not. Of the 72% non-prescribers prefer to refer their patients to a psychiatrist and 22% of them believe that antidepressants have no role in neurosurgery. Vascular and pediatric neurosurgeons as well as neurosurgeons at research hospitals showed the lowest prescription proportion, while general and brain tumor neurosurgeons and ones in private practice showed the highest prescription proportion. Surgeons with more than 20 year-experience had the lowest prescription proportion (43%). Type of practice and years of experience showed a statistically significant association with the prescription of antidepressant drugs across (p=0.002 and p=0.025, respectively). Type of practice and years of experience showed a statistically significant association with the proportion of antidepressants' prescribers in Turkish neurosurgery practice at the time of this survey. Non-prescriber neurosurgeons need to recognize the indications, whereas prescribers have to understand the risks of using antidepressants.

Medical Malpractice in Neurosurgery: A Comprehensive Analysis.

Of all specialists, neurosurgeons have the highest probability of facing a medical malpractice claim. Here we report the first specialty-wide review of malpractice claims in neurosurgery performed using a well-established national online legal database. The Westlaw legal research service (Thomson Reuters, Eagan, Minnesota, USA) was queried for jury verdicts and settlements related to neurosurgery and medical malpractice between 1985 and 2015. Case files were examined, and factors recorded included the age and sex of the patient, the state and year in which the verdict was reached, defendant specialties, award payouts, and alleged reasons for malpractice. Case files were sorted into neurosurgical subspecialties based on the nature of the condition and the type of treatment administered. A total of 516 cases were identified, and 343 cases were analyzed. A defendant's verdict was reached in 165 (48.1%) cases, and a plaintiff's verdict was reached in 93 (27.1%) cases. A settlement was reached in 81 cases (23.6%). The median payout for plaintiff's verdicts was $2,550,000 (range, $80,000-$216,849,187), and that for settlements was $1,300,000 (range, $100,000-$13,300,000). Procedural error (45.5%), a failure to diagnose (41.4%), or a failure to treat (42.9%) were the most commonly cited reasons for litigation. Neurosurgeons accounted for 21.1% of defendants. The median plaintiff award payout was highest for pediatric cases ($10,100,000). A defendant's verdict was reached in nearly one-half of the cases. In instances where a plaintiff's verdict was reached, large payouts were common, especially in pediatric and cerebrovascular cases. An emphasis on reducing procedural error, and making timely differential diagnoses, may reduce future litigation.

The Changing Face of Technologically Integrated Neurosurgery: Today's High-Tech Operating Room.

Over the last decade, surgical technology in planning, mapping, optics, robotics, devices, and minimally invasive techniques has changed the face of modern neurosurgery. We explore the current advances in clinical technology across all neurosurgical subspecialties, examine how clinical practice is being shaped by this technology, and suggest what the operating room of tomorrow may look like.

163 Analysis and Categorization of Complications Presented at a Neurosurgical Morbidity and Mortality Conference

Abstract INTRODUCTION There is no widely accepted neurosurgical complication classification system. We propose a novel neurosurgical complication classification system focusing on operative complications. We base our classification on our previously published paper on complications in endovascular neurosurgery. The system compiles the complication in five groups; indication errors, technical complications, judgement errors, critical events and procedural errors. METHODS We created our own neurosurgical complication classification system and prospectively analyzed and classified all our complications accordingly during the monthly morbidity and mortality conference at a single institution. The complications were captured and presented by neurosurgery chief residents. The classification was done by a single neurosurgery attending during the M&M conference. We compiled and analyzed our six-month results. We also performed a subgroup analysis of complications in neurosurgical subspecialties (general, spine, skull base, neuro-oncology, trauma, vascular, peripheral nerve and functional). RESULTS >There was a total of 64 neurosurgical complications during the six-month period; 55% of those were critical events and 28% were technical complications followed by Indication errors (9%), procedural (5%) and judgement errors (3%). Within the neurosurgical subspecialties, vascular neurosurgery (28%) had the most complications followed by spine (25%), trauma (14%), neuro-oncology (14%), general neurosurgery (11%), peripheral nerve (1%) and functional neurosurgery. CONCLUSION In this study, we present a novel neurosurgical complication classification system. Our six-month analysis reveals that the most common subtype of complications were critical events followed by technical complications. The subspecialty with most complications were vascular neurosurgery followed by spine and neuro-trauma. Our study has limitations in terms of subjective complication reporting and subjective analysis, as well as difficulty in interpreting patient outcomes and implications of the complications on patient life. Despite all the challenges, complication classification is a vital step in analyzing and understanding complications.

Academic Productivity of US Neurosurgery Residents as Measured by H-Index: Program Ranking with Correlation to Faculty Productivity

Engagement in research and academic productivity are crucial components in the training of a neurosurgeon. This process typically begins in residency training. In this study, we analyzed individual resident productivity as it correlated to publications across all Accreditation Council for Graduate Medical Education (ACGME)-accredited neurosurgery training programs in an attempt to identify how programs have developed and fostered a research culture and environment. We obtained a list of current neurosurgery residents in ACGME-accredited programs from the American Association of Neurological Surgeons database. An expanded PubMed and Scopus search was conducted for each resident through the present time. We tabulated all articles attributed to each resident. We then categorized the publications based on each neurosurgical subspecialty while in residency. A spreadsheet-based statistical analysis was performed. This formulated the average number of resident articles, h-indices, and most common subspecialty categories by training program. We analyzed 1352 current neurosurgery residents in 105 programs. There were a total of 10 645 publications, of which 3985 were resident first-author publications during the period of study. The most common subspecialties among all resident publications were vascular (24.9%), spine (16.9%), oncology (16.1%), pediatric (5.6%), functional (4.9%), and trauma (3.8%). The average resident published 2.9 first-author papers with average of 38.0 first-author publications by total residents at each program (range 0-241). The average h-index per resident is 2.47 ± 3.25. When comparing previously published faculty h-index program rankings against our resident h-index rankings, there is a strong correlation between the 2 datasets with a clear delineation between Top-20 productivity and that of other programs (average h-index 4.2 vs 1.7, respectively, P < .001). Increasing program size leads to a clear increase in academic productivity on both the resident and faculty level (average h-index 1.6, 1.9, 3.9 for 1, 2, and 3 resident per year programs, respectively, P < .001). Resident first-author publications correlated with recently described academic departmental productivity. Subspecialty resident publications are highest in cerebrovascular surgery. Resident research and publication is a key metric for assessing the productivity of academic neurosurgery programs and is consistent with one of the core foci of neurosurgical training.

Academic impact and rankings of neuroendovascular fellowship programs across the United States.

OBJECTIVE Publication has become a major criterion of success in the competitive academic environment of neurosurgery. This is the first study that has used departmental h index-and e index-based matrices to assess the academic output of neuroendovascular, neurointerventional, and interventional radiology fellowship programs across the continental US. METHODS Fellowship program listings were identified from academic and organization websites. Details for 37 programs were available. Bibliometric data for these programs were gathered from the Thomson Reuters Web of Science database. Citations for each publication from the fellowship's parent department were screened, and the h and e indices were calculated from non-open-surgical, central nervous system vascular publications. Variables including "high-productivity" centers, fellowship-comprehensive stroke center affiliation, fellowship accreditation status, neuroendovascular h index, e index ( h index supplement), h10 index (publications during the last 10 years), and departmental faculty-based h indices were created and analyzed. RESULTS A positive correlation was seen between the neuroendovascular fellowship h index and corresponding h10 index (R = 0.885; p < 0.0001). The mean, median, and highest faculty-based h indices exhibited positive correlations with the neuroendovascular fellowship h index (R = 0.662, p < 0.0001; R = 0.617, p < 0.0001; and R = 0.649, p < 0.0001, respectively). There was no significant difference (p = 0.824) in the median values for the fellowship h index based on comprehensive stroke center affiliation (30 of 37 programs had such affiliations) or accreditation (18 of 37 programs had accreditation) (p = 0.223). Based on the quartile analysis of the fellowship h index, 10 of 37 departments had an neuroendovascular h index of ≥ 54 ("high-productivity" centers); these centers had significantly more faculty (p = 0.013) and a significantly higher mean faculty h index (p = 0.0001). CONCLUSIONS The departmental h index and analysis of its publication topics can be used to calculate the h index of an associated subspecialty. The analysis was focused on the neuroendovascular specialty, and this methodology can be extended to other neurosurgical subspecialties. Individual faculty research interest is directly reflected in the research productivity of a department. High-productivity centers had significantly more faculty with significantly higher individual h indices. The current systems for neuroendovascular fellowship program accreditation do not have a meaningful impact on academic productivity.

Augmented reality in neurosurgery: a systematic review.

Neuronavigation has become an essential neurosurgical tool in pursuing minimal invasiveness and maximal safety, even though it has several technical limitations. Augmented reality (AR) neuronavigation is a significant advance, providing a real-time updated 3D virtual model of anatomical details, overlaid on the real surgical field. Currently, only a few AR systems have been tested in a clinical setting. The aim is to review such devices. We performed a PubMed search of reports restricted to human studies of in vivo applications of AR in any neurosurgical procedure using the search terms "Augmented reality" and "Neurosurgery." Eligibility assessment was performed independently by two reviewers in an unblinded standardized manner. The systems were qualitatively evaluated on the basis of the following: neurosurgical subspecialty of application, pathology of treated lesions and lesion locations, real data source, virtual data source, tracking modality, registration technique, visualization processing, display type, and perception location. Eighteen studies were included during the period 1996 to September 30, 2015. The AR systems were grouped by the real data source: microscope (8), hand- or head-held cameras (4), direct patient view (2), endoscope (1), and X-ray fluoroscopy (1) head-mounted display (1). A total of 195 lesions were treated: 75 (38.46%) were neoplastic, 77 (39.48%) neurovascular, and 1 (0.51%) hydrocephalus, and 42 (21.53%) were undetermined. Current literature confirms that AR is a reliable and versatile tool when performing minimally invasive approaches in a wide range of neurosurgical diseases, although prospective randomized studies are not yet available and technical improvements are needed.

Assessment of the "July Effect": outcomes after early resident transition in adult neurosurgery.

OBJECT Each July, 4th-year medical students become 1st-year resident physicians and have much greater responsibility in making management decisions. In addition, incumbent residents and fellows advance to their next postgraduate year and face greater challenges. It has been suggested that among patients who have resident physicians as members of their neurosurgical team, this transition may be associated with increased rates of morbidity and mortality, a phenomenon known as the "July Effect." In this study, the authors compared morbidity and mortality rates between the initial and later months of the academic year to determine whether there is truly a July Effect that has an impact on this patient population. METHODS The authors compared 30-day postoperative outcomes of neurosurgery performed by surgical teams that included resident physicians in training during the first academic quarter (Q1, July through September) with outcomes of neurosurgery performed with resident participation during the final academic quarter (Q4, April through June), using 2006-2012 data from the prospectively collected American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Regression analyses were performed on outcome data that included mortality, surgical complications, and medical complications, which were graded as mild or severe. To determine whether a July Effect was present in subgroups, secondary analyses were performed to analyze the association of outcomes with each major neurosurgical subspecialty, the postgraduate year of the operating resident, and the academic quarter during which the surgery was performed. To control for possible seasonal trends in certain diseases, the authors compared patient outcomes at academic medical centers to those at community-based hospitals, where procedures were not performed by residents. In addition, the efficiency of academic centers was compared to that of community centers in terms of operative duration and total length of hospital stay. RESULTS Overall, there were no statistically significant differences in mortality, morbidity, or efficiency between the earlier and later quarters of the academic year, a finding that also held true among neurosurgical subspecialties and among postgraduate levels of training. There was, however, a slight increase in intraoperative transfusions associated with the transitional period in July (6.41% of procedures in Q4 compared to 7.99% in Q1 of the prior calendar year; p = 0.0005), which primarily occurred in cases involving junior (2nd- to 4th-year) residents. In addition, there was an increased rate of reoperation (1.73% in Q4 to 2.19% in Q1; p < 0.0001) observed mainly among senior (5th- to 7th-year) residents in the early academic months and not paralleled in our community cohort. CONCLUSIONS There is minimal evidence for a significant July Effect in adult neurosurgery. Our results suggest that, overall, the current resident training system provides enough guidance and support during this challenging transition period.

Bradford's law: identification of the core journals for neurosurgery and its subspecialties.

Bradford's law describes the scatter of citations for a given subject or field. It can be used to identify the most highly cited journals for a field or subject. The objective of this study was to use currently accepted formulations of Bradford's law to identify core journals of neurosurgery and neurosurgical subspecialties. All original research publications from 2009 to 2013 were analyzed for the top 25 North American academic neurosurgeons from each subspecialty. The top 25 were chosen from a ranked career h-index list identified from previous studies. Egghe's formulation and the verbal formulation of Bradford's law were applied to create specific citation density zones and identify the core journals for each subspecialty. The databases were then combined to identify the core journals for all of academic neurosurgery. Using Bradford's verbal law with 4 zone models, the authors were able to identify the core journals of neurosurgery and its subspecialties. The journals found in the most highly cited first zone are presented here as the core journals. For neurosurgery as a whole, the core included the following journals: Journal of Neurosurgery, Neurosurgery, Spine, Stroke, Neurology, American Journal of Neuroradiology, International Journal of Radiation Oncology Biology Physics, and New England Journal of Medicine. The core journals for each subspecialty are presented in the manuscript. Bradford's law can be used to identify the core journals of neurosurgery and its subspecialties. The core journals vary for each neurosurgical subspecialty, but Journal of Neurosurgery and Neurosurgery are among the core journals for each neurosurgical subspecialty.

Simulation and resident education in spinal neurosurgery.

Background:A host of factors have contributed to the increasing use of simulation in neurosurgical resident education. Although the number of simulation-related publications has increased exponentially over the past two decades, no studies have specifically examined the role of simulation in resident education in spinal neurosurgery.Methods:We performed a structured search of several databases to identify articles detailing the use of simulation in spinal neurosurgery education in an attempt to catalogue potential applications for its use.Results:A brief history of simulation in medicine is given, followed by current trends of spinal simulation utilization in residency programs. General themes from the literature are identified that are integral for implementing simulation into neurosurgical residency curriculum. Finally, various applications are reported.Conclusion:The use of simulation in spinal neurosurgery education is not as ubiquitous in comparison to other neurosurgical subspecialties, but many promising methods of simulation are available for augmenting resident education.

Introduction: Health economics and the neurosurgeon.

Value of care has emerged as a framework to redesign health care. In determining value, physicians will be held accountable for both clinical outcomes and cost consciousness in resource utilization; therefore, engaging physicians in the study of health economics and health care–related costs remains central in the quest for valued care delivery. The featured topic of health economics and the neurosurgeon in this issue of Neurosurgical Focus represents an effort to meet this need for the readership. Health economics, as a subdivision of economics, rigorously examines the challenges faced in promoting health for all. It encompasses the study of issues of efficiency, effectiveness, value, and behavior in the production and consumption of health and medical services. Williams has described the scope of health economics in eight areas: 1) what, other than health care, influences health; 2) what is health and what is its value; 3) demand for health care; 4) supply of health care, including cost analysis; 5) microeconomic evaluation at the treatment level, including economic evaluations; 6) market equilibrium; 7) macroeconomic evaluation; and 8) planning, budgeting, and regulation mechanisms.1–3 Williams’ conceptual model, known as the “plumbing diagram,” demonstrates how health economics per se encompasses interrelated activities that affect every neurosurgeon’s daily practice. It stresses how multiple professionals— health economists, epidemiologists, statisticians, physicians, administrators, politicians, and so forth—are essential to the development of this field of knowledge. Our call for papers was therefore very broad, aiming to encourage our scientific community to share their best work in all areas of health economics. Authors of submitted manuscripts merit commendation for their work: over 45 manuscripts were reviewed. The papers published in this edition represent the best examples of various types of economic assessments, offering different perspectives and using varied data sources. A multidisciplinary team reviewed all manuscripts to ensure the methodology section was comprehensive and detailed; thus, readers of Neurosurgical Focus will be able to use this edition as a reference for future endeavors. Authors were also encouraged to provide a detailed limitation section to provide critical context and nuance that may impact observations. The first few articles feature an overview on health care economics in general as well as costing methodology, providing readers with the knowledge and tools required to appraise published economic evaluations and to direct high-quality health care economics assessments (McLaughlin, Ong et al.). They also introduce the readers to a costing model that has gained worldwide popularity in health economics: time-driven activity-based costing (TDABC; McLaughlin, Burke et al.). This model estimates the cost of each resource used for treating a patient’s medical condition and combines it with the quantity of time each resource is used for each activity during a patient’s care. McLaughlin and colleagues describe their implementation process, as well as lessons learned across the care continuum, and report how TDABC has actively engaged health care providers in costing activities and care redesign within their institutions. Subsequent articles discuss economic evaluations and cost analysis and contain examples applied throughout various neurosurgical subspecialties. All authors have taken their economic assessments one step further by providing one or many of the following: 1) cost trends regarding year of treatment, geographic location of the hospital, hospital characteristics, and so forth (articles by Menger et al., Lam et al., Little et al., and Sheen James et al.); 2) drivers of increased cost or resource utilization (Little et al.; Lam et al.; and McLaughlin, Martin et al.); 3) integration of cost analysis data in decision making (Menger et al. and Mansfield et al.); 4) integration of modeling and development of cost models (Lam et al. and Zygourakis et al.); and 5) Introduction

An application of Bradford's law: identification of the core journals of pediatric neurosurgery and a regional comparison of citation density.

Bradford's law describes the number of core journals in a given field or subject and has recently been applied to neurosurgery. The objective of this study was to use currently accepted formulations of Bradford's law to identify core journals of pediatric neurosurgery. An additional analysis was completed to compare regional dependence on citation density among North American and European neurosurgeons. All original research publications from 2009 to 2013 were analyzed for the 25 top publishing pediatric neurosurgeons in North America and Europe, which were sampled to construct regional citation databases of all journal references. Regional differences were compared with each database. Egghe's formulation and the verbal formulation of Bradford's law were applied to create specific citation density zones and identify the core journals. Regional comparison demonstrated a preference for the Journal of Neurosurgery and Child's Nervous System, respectively, but four of the top five journals were common to both groups. Applying the verbal formulation of Bradford's law to the North American citation database, a pattern of citation density was identified across the first three zones. Journals residing in the most highly cited first zone are presented as the core journals. Bradford's law can be applied to identify the core journals of neurosurgical subspecialties. While regional differences exist between the most highly cited and most frequently published in journals among North American and European pediatric neurosurgeons, there is commonality between the top five core journals in both groups.

Current state-of-the-art and future perspectives of robotic technology in neurosurgery.

Neurosurgery is one of the most demanding surgical specialties in terms of precision requirements and surgical field limitations. Recent advancements in robotic technology have generated the possibility of incorporating advanced technological tools to the neurosurgical operating room. Although previous studies have addressed the specific details of new robotic systems, there is very little literature on the strengths and drawbacks of past attempts, currently available platforms and prototypes in development. In this review, the authors present a critical historical analysis of the development of robotic technology in neurosurgery as well as a comprehensive summary of the currently available systems that can be expected to be incorporated to the neurosurgical armamentarium in the near future. Finally, the authors present a critical analysis of the main technical challenges in robotic technology development at the present time (such as the design of improved systems for haptic feedback and the necessity of incorporating intraoperative imaging data) as well as the benefits which robotic technology is expected to bring to specific neurosurgical subspecialties in the near future.

Efficacy of a new video-based training model in spinal surgery

Background:An important part of neurosurgical training is the improvement of surgical skills. Acquiring microsurgical skills follows a learning curve, influenced by specific exercises, feedback, and training. Aim of training should be rapid learning success. The study shows the way in which video-based training can influence the learning curve.Methods:Over a period of 18 months (2011-2012) 12 residents were evaluated in spinal surgery (12 cases per resident) by a skilled evaluator based on different criteria. The evaluation criteria (exposition of important anatomy, intraoperative bleeding, efficacy of using bipolar cauterization) were weighted and added to a single quality-score. The participating residents were divided into two groups. Only one group (n = 5) received video-based training.Results:Residents showed an individually different but explicit increase in microsurgical skills. The quality-score during the first surgery compared with the end point of the study demonstrated a faster improvement of surgical skills in the group with video-based training than in the group without special training. Considering all residents together, the video-training group displayed a steeper gradient of microsurgical success. Comparison of the single resident's microsurgical skills showed individual disparities. Various biases that influence the learning success are under examination.Conclusion:Video-based training can improve microsurgical skills, leading to an improved learning curve. An earlier entry of the learning curve plateau in the video-training group promotes a higher acquisition of surgical skills. Because of the positive effect, we plan to apply the video-based training model to other neurosurgical subspecialties, especially neurovascular and skull base surgery.

Impact of Fellowship Training on Research Productivity in Academic Neurological Surgery

An increasing number of neurological surgeons have sought fellowship training in recent years, and previous analyses have suggested these practitioners are more likely to pursue an academic career. Scholarly productivity is a key component in academic advancement. We used the h-index to evaluate whether fellowship training impacts research productivity and whether any differences exist in scholarly output among practitioners in the various neurosurgical subspecialties. Online listings from academic neurological surgery departments were used to organize faculty by academic rank and fellowship training. Using the Scopus database, we calculated the h-index for 869 full-time clinical faculty. Mean h-index did not differ between fellowship- and nonfellowship-trained practitioners (h= 12.6 vs. 13.0, P= 0.96). When organized by academic rank, the difference between h-indices of those who completed fellowships was substantially greater at all ranks, with statistical significance at the associate professor rank (P= 0.003). Upon further examination by individual subspecialties, significant differences in relative research impact were noted (P < 0.0001). The stereotactic and functional fellowship was found to have the greatest mean h-index score, whereas the trauma/critical care fellowship had the lowest. No significant difference existed between the mean h-index scores of neurological surgeons who completed fellowships and those who did not. However, when stratified by academic rank, a trend was observed showing greater mean h-index scores for those who completed fellowships. This trend persists across nearly all subspecialties. Overall, being a senior faculty member corresponds with a greater h-index score, regardless of whether a fellowship was completed.

Part I: The Application of the h-Index to Groups of Individuals and Departments in Academic Neurosurgery

The h-index was introduced as a means of quantifying the contribution a researcher makes to the scientific literature. We evaluated the h-index for academic neurosurgeons to assess the various methods of calculation and to determine whether the h-index can be used to differentiate groups of individuals by various classifications. The h-index was calculated for all neurosurgeons from 10 institutions ranked highly by 2012 U.S. News & World Report plus the authors' institution via Scopus. The h-index also was calculated manually to evaluate its accuracy. The average h-index was calculated for groups on the basis of sex, academic rank, years in practice, institution, and subspecialty. Cumulative and mean h-indices were calculated for each department. The median h-index for the 188 neurosurgeons was 16 (mean, 19.71; range, 0-61). There was a positive association between the h-index, academic rank, and years posttraining. There was a significant difference between the "manually calculated" and automated h-indices, particularly for more senior physicians. The difference in h-index between men and women was not statistically significant. Among subspecialties, vascular surgeons had the greatest average h-index and general neurosurgeons had the lowest. There were significant shifts in departmental rankings when the cumulative or mean departmental indices were compared with the U.S. News & World Report rankings. Application of the h-index as a bibliometric in neurosurgery can distinguish academic productivity on the basis of academic rank, years posttraining, and neurosurgical subspecialties. The application of the h-index to compare departments is problematic and, at this time, not reliable.

A comparative analysis of neurosurgical online education materials to assess patient comprehension

Americans have increasingly utilized the internet as a first-line resource for a variety of information, including healthcare-oriented materials. Therefore, these online resources should be written at a level the average American can understand. Patient education resources specifically written for and available to the public were downloaded from the American Association of Neurological Surgeons website and assessed for their level of readability using the Flesch Reading Ease, Flesch-Kincaid Grade Level, Simple Measure of Gobbledygook Grading, Coleman-Liau Index, and Gunning-Fog Index. A total of 71 subsections from different neurosurgical specialties were reviewed, including Cerebrovascular, Spine and Peripheral Nerves, Neurotrauma and Critical Care, Pain, Pediatric, Stereotactic and Functional, and Tumor material. All neurosurgical subspecialty education material provided on the American Association of Neurological Surgeons website was uniformly written at a level that was too high, as assessed by all modalities. In order to reach a larger patient population, patient education materials on the American Association of Neurological Surgeons website should be revised with the goal of simplifying readability.

Pituitary surgery: legacies from the past

Pituitary surgery is a recent development in neurosurgery and most of the surgical techniques concerned have been described within the last century. We provide a historical perspective by reviewing the major steps in the development of this neurosurgical subspecialty through the ages. We concentrate on the most important figures whose advances in the study of the physiology and anatomy of the pituitary are most significant. This journey into the past will demonstrate that our current knowledge is the summation of a long road of investigation.

The development of neurosurgery at the University of Utah, 1955-2009.

Located in the geographic Intermountain West, the Department of Neurosurgery at the University of Utah has undergone remarkable growth and transformation since the appointment of the first full-time clinical faculty member in 1955. The Department has provided broad neurosurgical services to an expanding community while fulfilling its academic mission of pushing the frontiers within neurosurgical subspecialties. The history of neurosurgery in the Salt Lake Valley and the achievements of the Department of Neurosurgery, including the seminal development of early cranial stereotactic devices, are reviewed in this article.

The history of neurosurgery in Memphis: the Semmes-Murphey Clinic and the Department of Neurosurgery at the University of Tennessee College of Medicine

Neurological surgery was defined as a separate surgical specialty by Harvey Cushing and a few other surgeons, most of whom were trained and influenced by Cushing. One of these, Raphael Eustace Semmes, became the first neurosurgeon in Memphis, Tennessee, in 1912. After World War II, Semmes and his first associate, Francis Murphey, incorporated the Semmes-Murphey Clinic, which has been primarily responsible for the growth of the Department of Neurosurgery at the University of Tennessee Health Science Center in Memphis, as well as the development of select neurosurgical subspecialties in Memphis area hospitals.