Neurosurgical Trainee Research Articles

Should all surgical trainees rotate through the emergency department?

Reflection from a neurosurgical trainee.

The management and outcome for patients with chronic subdural hematoma: a prospective, multicenter, observational cohort study in the United Kingdom.

OBJECTIVE Symptomatic chronic subdural hematoma (CSDH) will become an increasingly common presentation in neurosurgical practice as the population ages, but quality evidence is still lacking to guide the optimal management for these patients. The British Neurosurgical Trainee Research Collaborative (BNTRC) was established by neurosurgical trainees in 2012 to improve research by combining the efforts of trainees in each of the United Kingdom (UK) and Ireland's neurosurgical units (NSUs). The authors present the first study by the BNTRC that describes current management and outcomes for patients with CSDH throughout the UK and Ireland. This provides a resource both for current clinical practice and future clinical research on CSDH. METHODS Data on management and outcomes for patients with CSDH referred to UK and Ireland NSUs were collected prospectively over an 8-month period and audited against criteria predefined from the literature: NSU mortality < 5%, NSU morbidity < 10%, symptomatic recurrence within 60 days requiring repeat surgery < 20%, and unfavorable functional status (modified Rankin Scale score of 4-6) at NSU discharge < 30%. RESULTS Data from 1205 patients in 26 NSUs were collected. Bur-hole craniostomy was the most common procedure (89%), and symptomatic recurrence requiring repeat surgery within 60 days was observed in 9% of patients. Criteria on mortality (2%), rate of recurrence (9%), and unfavorable functional outcome (22%) were met, but morbidity was greater than expected (14%). Multivariate analysis demonstrated that failure to insert a drain intraoperatively independently predicted recurrence and unfavorable functional outcome (p = 0.011 and p = 0.048, respectively). Increasing patient age (p < 0.00001), postoperative bed rest (p = 0.019), and use of a single bur hole (p = 0.020) independently predicted unfavorable functional outcomes, but prescription of high-flow oxygen or preoperative use of antiplatelet medications did not. CONCLUSIONS This is the largest prospective CSDH study and helps establish national standards. It has confirmed in a real-world setting the effectiveness of placing a subdural drain. This study identified a number of modifiable prognostic factors but questions the necessity of some common aspects of CSDH management, such as enforced postoperative bed rest. Future studies should seek to establish how practitioners can optimize perioperative care of patients with CSDH to reduce morbidity as well as minimize CSDH recurrence. The BNTRC is unique worldwide, conducting multicenter trainee-led research and audits. This study demonstrates that collaborative research networks are powerful tools to interrogate clinical research questions.

The management and outcome for patients with chronic subdural hematoma: a prospective, multicenter, observational cohort study in the United Kingdom.

Symptomatic chronic subdural hematoma (CSDH) will become an increasingly common presentation in neurosurgical practice as the population ages, but quality evidence is still lacking to guide the optimal management for these patients. The British Neurosurgical Trainee Research Collaborative (BNTRC) was established by neurosurgical trainees in 2012 to improve research by combining the efforts of trainees in each of the United Kingdom (UK) and Ireland's neurosurgical units (NSUs). The authors present the first study by the BNTRC that describes current management and outcomes for patients with CSDH throughout the UK and Ireland. This provides a resource both for current clinical practice and future clinical research on CSDH. Data on management and outcomes for patients with CSDH referred to UK and Ireland NSUs were collected prospectively over an 8-month period and audited against criteria predefined from the literature: NSU mortality < 5%, NSU morbidity < 10%, symptomatic recurrence within 60 days requiring repeat surgery < 20%, and unfavorable functional status (modified Rankin Scale score of 4-6) at NSU discharge < 30%. Data from 1205 patients in 26 NSUs were collected. Bur-hole craniostomy was the most common procedure (89%), and symptomatic recurrence requiring repeat surgery within 60 days was observed in 9% of patients. Criteria on mortality (2%), rate of recurrence (9%), and unfavorable functional outcome (22%) were met, but morbidity was greater than expected (14%). Multivariate analysis demonstrated that failure to insert a drain intraoperatively independently predicted recurrence and unfavorable functional outcome (p = 0.011 and p = 0.048, respectively). Increasing patient age (p < 0.00001), postoperative bed rest (p = 0.019), and use of a single bur hole (p = 0.020) independently predicted unfavorable functional outcomes, but prescription of high-flow oxygen or preoperative use of antiplatelet medications did not. This is the largest prospective CSDH study and helps establish national standards. It has confirmed in a real-world setting the effectiveness of placing a subdural drain. This study identified a number of modifiable prognostic factors but questions the necessity of some common aspects of CSDH management, such as enforced postoperative bed rest. Future studies should seek to establish how practitioners can optimize perioperative care of patients with CSDH to reduce morbidity as well as minimize CSDH recurrence. The BNTRC is unique worldwide, conducting multicenter trainee-led research and audits. This study demonstrates that collaborative research networks are powerful tools to interrogate clinical research questions.

Can the transition process from foundation doctor to neurosurgical specialty trainee be improved through "learner-centered induction programs"?

The transition period from foundation program doctor to specialty trainee can be difficult for junior doctors. This difficult period often acts as a major obstacle for learning in the workplace. Existing induction programs are commonly seen as inadequate at easing this transition, and therefore, a pilot study intervention was undertaken to assess if the initiation of “learner-centered induction programs” could help improve the confidence, knowledge acquisition, and satisfaction of junior doctors as they begin specialty training in neurosurgery. Ethnographic and anecdotal evidences were collated from junior doctors, specialty trainees, and consultants in order to investigate if further work on this subject would be beneficial. All participants were working in the Department of Neurosurgery at University Hospital Coventry and Warwickshire, Coventry, UK, over a 4-week period in March/April 2015. A review of the relevant literature was also undertaken. This report found that despite the reservations around the increased organizational demands of induction programs of this nature, as well as concerns around a single junior doctor covering the ward alone during the induction period, feedback following the intervention was largely positive. Junior doctors appreciated being taught about their roles and responsibilities from their predecessors as well as deciding among themselves what topics they wanted covering. As a result, the induction sessions tended to focus on clinical skills rather than theoretical knowledge, which most of the junior doctors believed they could cover adequately in their own time. The junior doctors felt that they benefited from learning/refreshing their relevant practical skills in a safe environment under senior supervision, prior to starting on the wards. Finally, as the induction program was of a greater duration than the traditional half day, they felt they had sufficient time to ask questions and address concerns while “on the job”. Overall, “learner-centered induction programs” did appear to show promise in this pilot study with regards to increasing the confidence of junior doctors starting a neurosurgical placement and helped ease the transition process from foundation doctor to specialty trainee in neurosurgery. We believe further work to formalize and quantify these findings using questionnaires and a larger sample group as well as across successive is indicated and may help junior doctor learning and transition processes in future practice.

Smartphone use in neurosurgery? APP-solutely!

Background:A number of smartphone medical apps have recently emerged that may be helpful for the neurosurgical patient, practitioner, and trainee. This study aims to review the current neurosurgery-focused apps available for the iPhone, iPad, and Android platforms as of December 2013.Methods:Two of the most popular smartphone app stores (Apple Store and Android Google Play Store) were surveyed for neurosurgery-focused apps in December 2013. Search results were categorized based on their description page. Data were collected on price, rating, app release date, target audience, and medical professional involvement in app design. A review of the top apps in each category was performed.Results:The search resulted in 111 unique apps, divided into these 7 categories: 16 (14%) clinical tools, 17 (15%) conference adjunct, 27 (24%) education, 18 (16%) literature, 15 (14%) marketing, 10 (9%) patient information, and 8 (7%) reference. The average cost of paid apps was $23.06 (range: $0.99-89.99). Out of the 111 apps, 71 (64%) were free, 48 (43%) had reviews, and 14 (13%) had more than 10 reviews. Seventy-three (66%) apps showed evidence of medical professional involvement. The number of apps being released every year has been increasing since 2009.Conclusions:There are a number of neurosurgery-themed apps available to all audiences. There was a lack of patient information apps for nonspinal procedures. Most apps did not have enough reviews to evaluate their quality. There was also a lack of oversight to validate the accuracy of medical information provided in these apps.

An evaluation of websites to help neurosurgical trainees learn histopathology

Introduction. Knowledge of histopathology is essential for good neurosurgical practice but current pressures on neurosurgical trainees’ time restrict opportunities to learn histopathology by traditional methods. The internet offers a possible alternative resource. The aim of this project was to assess the existing, free, internet-based resources for learning histology and histopathology, from the perspective of a neurosurgical trainee. Methods. English language websites were evaluated by an expert, and by neurosurgical trainees, for the range of content, academic credibility, quality of the histopathological images, quality of supporting content, educational features and the usability. Results. Thirty-nine websites were examined in detail by the author. Although many websites were useful, no individual website met all the requirements. Five neuropathology websites were clearly superior to the others. These were then assessed by neurosurgical trainees. The results of the assessment, a brief resume of each website, and the characteristics of a good website for the surgical trainees to learn pathology are discussed. Conclusions. The best websites featured a large number of high-quality images, accurate, detailed clinical and pathophysiological information, labelling or description of individual images, and organisation by organ system. Free internet sites can offer a valuable learning resource to supplement textbooks and clinical pathology sessions.

Morbidity and mortality meetings for neurologists

One of the advantages of being a neurologist in Edinburgh is that we can, if we wish, meet up with our neurosurgical colleagues every morning at a short x ray...

A basic model for practice of intracranial microsurgery

Background Intracranial microsurgical procedures often take place in a deep location, with a limited access space, necessitating the use of long knee-bend instruments and limiting the degree of movement. We devised an easily accessible model that allows the neurosurgical trainee to gain familiarity with intracranial microsurgical techniques. Methods The model consists of a pedestal, on which 2 movable vices are placed. The object to be practiced on can be placed on a working area, or the vices may hold the object. The pedestal can be covered by a box with a centered hole. When using this box, the vices can move together in the vertical plane over a trajectory of 5.5 cm to simulate superficial or deep microsurgical procedures. To simulate several sizes of hypothetical craniotomies, 3 rings can be used to decrease the diameter of centered hole in the box. Results Using the model, these techniques were judged to be technically more challenging and difficult to execute through the centered hole. Conclusions Our model can be a useful method to train for basic intracranial microsurgery.

Neurosurgery: Principles and Practice

This new book should be on every neurosurgical trainee's desk. A group of acknowledged experts from the UK and the US have been selected by the editors to contribute chapters that cover their respective topics in a practical, yet innovative, way. Their aim to present an up-to-date synopsis, for residents and registrars in training and recent graduates of training programmes, has been very successful. The chapters are arranged in broad topics, which begin with investigations of the neurosurgical patient, followed by a section on peri-operative care including anaesthesia and intensive care. The next section deals with areas where recent technical developments have occurred: neuro-endoscopy, image-guided surgery and stereotactic radiosurgery. Subsequently, a group of chapters are devoted to the management of intracranial tumours including low- and high-grade gliomas, sella and parasella lesions, meningiomas, intraventricular and pineal region tumours together with those involving the cerebellar pontine angle. A section on skull-based tumours not dealt with elsewhere is followed by a chapter on the management of cerebral metastases and primary cerebral lymphoma. The vascular section begins with a review of the physiology of cerebral blood flow and techniques employed for pre- and peri-operative assessment. An excellent chapter on the management of patients by interventional neuroradiology is quite properly sandwiched between those dealing with aneurysmal subarachnoid haemorrhage and arterial venous malformations, given the importance of this technique to the management of patients with such conditions. Somewhat illogically, the chapter on ischaemic stroke and carotid endarterectomy is at the very back of the book rather than being included in this section. It is refreshing to see a chapter on the rehabilitation of neurologically injured patients alongside those dealing with severe head and spinal injuries. In the past, this area has been neglected but the importance of multidisciplinary teams of rehabilitation specialists to the management of postoperative patients is obvious to all who work in a neuroscience department. Hydrocephalus is dealt with separately from the section on paediatric neurosurgery, which comprises chapters on the management of sporadic and syndromic craniosynostosis, spinal dysraphism and paediatric neuro-oncology. Subsequent sections deal with the spine, peripheral and cranial nerve injury, functional neurosurgery and infection. I was surprised to find that degenerative disease of the lumbar and thoracic spine is not included, given the large number of patients who present to all neurosurgical units and the recent controversies in surgical management by instrumented fusion or disc replacement. Despite these criticisms, this is an excellent new book, full of applied basic neuroscience and practical clinical advice yet unafraid to confront difficulties in the management of neurosurgical pathology. It bridges the gap between journal articles and reviews on the one hand and multi-volume texts on the other. It can be recommended for all those beginning a neurosurgical career but there is also much in it which will refresh the knowledge of established surgeons, particularly when subspecialisation has meant that they have become less familiar with some areas of neurosurgical practice. I consider this to be an excellent book that will have broad appeal across neurosurgery.

Appropriate technology for neurosurgery

Though more than 50 years have elapsed since neurosurgery has come to the developing countries, vast areas of the population do not have neurosurgical facilities available to them. This is due not only to the economic status of the country but also as a result of the training that the neurosurgical trainee receives. It is proposed in this article that while the young neurosurgeon must, without doubt, be very well trained in the latest technology, at the same time he must be taught to work with confidence with whatever facilities are available without any feeling of inferiority. The locally available appropriate technology should be fully utilized. The neurosurgeon at the periphery must be provided with the minimum essential neurosurgical equipment and also with good compensation. The concerned governments, the public, neurosurgical teachers, and neurosurgical societies and journals have a great role to play in this difficult task.

EDITORIAL Britain in Europe: training the neurosurgeons of the future

It is an obvious truism to state that education and training, tempered by experience, continue throughout the professional life of a neurosurgeon. For the trainee what is essential is the level of education and training that are necessary before he is allowed to practise independently and provide a safe and effective service to his patients. In an ideal world, it is best to start with what is required of an independent neurosurgeon, and work backwards to what are the essential knowledge, training and surgical expertise of a neurosurgical trainee; and in between comes the assessment of an individual trainee as to whether or not he ful® ls the minimal requirements. This rather simplistic schema is complicated by many factors, two of which currently predominate: a rapidly changing technology and a steady progression towards sub-specialization. The present UK system of training and assessment has been steadily evolving over the past 20 years and should be well known to all UK neurosurgeons. The present system of assessment is based on certi® cation by the Specialist Advisory Committee in Neurosurgery (SAC) which requires reports from the local trainers and an assessment by examination by other neurosurgeons not involved in an individual trainee’s training (FRCS.SN of the Intercollegiate Board of the Royal Colleges of Surgeons). Overall the verdict from the majority of neurosurgeons would probably be that by and large it seems

Neurosurgery at the Toronto General Hospital, 1924-1990: Part 2.

Part 1 of this two part series outlined the beginning of Canadian neurosurgery and neurosurgical training at the Toronto General Hospital under Kenneth G. McKenzie, and described the efforts of E. Harry Botterell, McKenzie’s neurosurgical trainee and successor, in establishing the Toronto school of neurosurgery. This second part reviews the course of neurosurgery at the Toronto General until the creation of The Toronto Hospital.