Neurosurgical Work Research Articles

Admissions: Life as a Brain Surgeon

Admissions: Life as a Brain Surgeon

Neurosurgical Publication—Should We Publish at Any Cost? An In-Depth Analysis of Costs Incurred in Publication

With the recent paradigm shift in neurosurgical publications, open access (OA) publishing is burgeoning along with traditional publishing methods. We aimed to explore costs of publication across 53 journals. We identified 53 journals publishing neurosurgical work. Journal type, submission and open access charges, color print fees, impact indicators, publisher, and subscription prices were obtained from journal and publisher websites. Costs were unified in U.S. dollars. Mean prices per journal were used to equilibrate membership and subscription discounts. Correlations were performed using Spearman ρ (P < 0.05). Of 53 journals, 12 were OA only, 40 were hybrid, and 1 was traditional. Submission costs were provided by 22 and 43 journals, respectively, by the end of phase 1 and 2 (prices always for phase 2: 26 free of charge, 4 <$500, and 1 <$1000). Median OA charge was $3286 (49 journals; range, $0-$7827). Of 53 journals, 36 did not list print fees for color figures (29 in phase 2). Median fee estimate per figure was $422 (range, $25-$1060). Median personal subscription for 1 year was $344 (range, $60-$1158; 48 journals). Median institutional subscription for 1 year was $2082 (range, $38-$5510; 34 journals). There was a mild positive correlation between Journal Impact Factor and OA fees (ρ= 0.287, P= 0.046). The lack of easily accessible information about neurosurgical publications, such as submission costs or OA charges, creates an unnecessary hurdle and should be remedied. Publishing in neurosurgery should be a positive learning experience, and cost should not be a limiting factor.

Prof. B. Ramamurthi - A Glimpse into his Contributions to Neuroscience.

Prof B Ramamurthi was a pioneer of Indian neurosurgery and a major force in the development of Indian neuroscience. Founding the Madras Institute of Neurology and later the A Lakshmipathi Neurosurgical Centre (ALNC), both at Madras (or Chennai as it is now called), he developed centres of excellence in his career that spanned over five decades. During this period of time he made Madras, a destination for neurosurgery and neuroscience. Along with his colleagues a large number of publications were produced which influenced the world. Notable among his contributions were those in Stereotaxy for movement disorders, epilepsy, pain and psychiatric illness. He also had notable contributions in brain tumours especially acoustic neurinomas and pituitary tumours. His papers on the low incidence of aneurysms is still quoted widely. Head injuries formed a major part of the neurosurgical work and major contributions were made in that field too. As a developing country with socio-economic issues, infections of the nervous system were seen commonly. His publications on tuberculomas of the brain are noteworthy. He was intrigued by the neurophysiological basis of consciousness. He writings on the subject reflect his attempt to bring together ancient eastern thoughts and concepts of consciousness and life and western science. In the later part of his career he spoke on ethics in and the changing milieu of neurosurgery. While contributions to spinal surgery were not seen in the first half of his career, he along with his colleagues from ALNC published original articles on spinal surgery especially tumours and OPLL. Prof B Ramamurthi, has not only influenced, taught and mentored, during his lifetime, a great many neuroscientists, but he also continues to do so through his publications which continue to be relevant in todays world. A glimpse into his contributions show us how without the technology of today a lot was achieved - and we need to see that, to inspire us to achieve more and to strive for greater heights.

A researcher and physician who gained international fame: Otfrid Foerster (1873-1941) as Nobel Prize candidate

Dieser Aufsatz befasst sich mit den Nobelpreisnominierungen für den Neurologen und Neurochirurgen Otfrid Foerster (1873–1941). Foerster wurde 17 Mal für den Nobelpreis für Physiologie oder Medizin nominiert. Aufbauend auf Akten des Stockholmer Nobelpreisarchives, Primär- und Sekundärliteratur wird auf folgende Fragen eingegangen: Welche Gründe gab es für Foersters Nominierungen? Wie sah die Beziehung zwischen ihm und seinen Nominatoren aus? Warum hat er letztlich den Nobelpreis nicht erhalten? Das Gros der Nominatoren für Foerster hob als Hauptmotiv sein gemeinsam mit Oswald Bumke herausgegebenes Handbuch der Neurologie hervor. Den Nominatoren zufolge hatte Foerster mit diesem Handbuch einen enormen Einfluss auf die Neurologie seiner Zeit. Darüber hinaus wurde sein „ehrenvoller Charakter“ in den Nominierungsbriefen unterstrichen. Für das Nobelkomitee waren diese Begründungen jedoch nicht ausreichend: Die Mitglieder stuften das Handbuch nicht als originäre Forschungsleistung ein. Foersters Ruhm reicht trotzdem bis in die Gegenwart, etwa in Form einer seit 1953 von der Deutschen Gesellschaft für Neurochirurgie vergebenen Ehrung, die seinen Namen trägt (Otfrid-Foerster-Medaille).

Impact of the Coronavirus Disease 2019 Pandemic on Working and Training Conditions of Neurosurgery Residents in Latin America and Spain

BackgroundThe coronavirus disease 2019 (COVID-19) pandemic has exerted a significant impact on health care workers. Recent studies have reported the detrimental effects of the pandemic on neurosurgery residents in North America, Asia, and Italy. However, the impact of the pandemic on neurosurgical training in Latin America and Spain has not yet been reported. In the present report, we describe effects of COVID-19 on training and working conditions of neurosurgery residents in these countries.MethodsAn electronic survey with 33 questions was sent to neurosurgery residents between September 7, 2020 and October 7, 2020. Statistical analysis was made in SPSS version 25.ResultsA total of 293 neurosurgery residents responded. The median age was 29.47 ± 2.6 years, and 79% (n = 231) were male. Of respondents, 36.5% (n = 107) were residents training from Mexico; 42% surveyed reported COVID symptoms and 2 (0.7%) received intensive care unit care; 61.4% of residents had been tested for COVID and 21.5% had a positive result; 84% of the respondents mentioned persisted with the same workload (≥70 hours per week) during the pandemic. Most residents from Mexico were assigned to management of patients with COVID compared with the rest of the countries (88% vs. 68.3%; P < 0.001), mainly in medical care (65.4% vs. 40.9%; P < 0.001), mechanical ventilators (16.8% vs. 5.9%; P = 0.003), and neurologic surgeries (94% vs. 83%; P = 0.006).ConclusionsOur results offer a first glimpse of the changes imposed by the COVID-19 pandemic on neurosurgical work and training in Latin America and Spain, where health systems rely strongly on a resident workforce.

Association of Neurosurgical Work Relative Value Units with Objective Markers of Operative Complexity

Relative value units (RVUs) form the backbone of health care service reimbursement calculation in the United States. However, it remains unclear how well RVUs align withobjective measures of procedural complexity within neurosurgery. The 2018 American College of Surgeons National Surgical Quality Improvement Program database was queried for neurosurgical procedures with >50 patients, using Current Procedural Terminology (CPT) codes. Length of stay (LOS), operative time, mortality, and readmission and reoperation rates were collected for each code and a univariate correlation analysis was performed, with significant predictors entered into a multivariate logistic regression model, which generated predicted work RVUs, which were compared with actual RVUs to identify undervalued and overvalued procedures. Among 64 CPT codes, LOS, operative time, mortality, readmission, and reoperation were significant independent predictors of work RVUs and together explained 76% of RVU variance in a multivariate model (R2= 0.76). Using a difference of >1.5 standard deviations from the mean, procedures associated with greater than predicted RVU included surgery for intracranial carotid circulation aneurysms (CPTs 61697 and 61700; residual RVU= 12.94 and 15.07, respectively), and infratemporal preauricular approaches to middle cranial fossa (CPT 61590; residual RVU= 15.39). Conversely, laminectomy/foraminotomy for decompression of additional spinal cord, cauda equina, and/or nerve root segments (CPT 63048; residual RVU= -21.30), transtemporal craniotomy for cerebellopontine angle tumor resection (CPT 61526; residual RVU= -9.95), and brachial plexus neuroplasty (CPT 64713; residual RVU= -11.29) were associated with lower than predicted RVU. Work RVUs for neurosurgical procedures are largely predictive of objective measures of surgical complexity, with few notable exceptions.

Neurosurgical Work during the Napoleonic Wars: George James Guthrie's Experience.

Involved in what is still considered, along with the two world wars of the 20th century, as one of the major conflicts in Europe, George James Guthrie (1785-1856) was the most famous English army surgeon of the Napoleonic wars. After treating the injured throughout the Peninsular Campaign (1808-1814), in 1815 and then in 1842 he published two major books dealing with cranial and brain injuries, among other topics. In these books, we can find, for example, an early description of the plantar reflex further described by Joseph Babinsky, accurate descriptions of the clinical signs of intracranial hypertension, and details of the physiopathology of subdural and epidural haematomas. Skull fractures are also discussed intensively, along with the indications for trepanation, a much-debated issue at the turn of the 19th century. The dura was often the limit of the surgical field for Guthrie. Nevertheless, he tried to rationalize the use of trepanation and favoured its use in two main cases: in cases of depressed skull bones, jammed bone fragments or debris irritating the dura or the brain and in cases of life-threatening cerebral compression caused by supposed blood clots. In their works, Guthrie and his contemporaries did not address neurosurgery in the modern sense of the word, but rather 'cranial surgery' in most cases. Guthrie, who saw so many patients with brain injuries and amputations, failed to understand that cerebral functions could be localized to the cortex and neglected to describe the phantom limb phenomenon, as did most of his contemporaries.

Neurosurgical work during the Napoleonic wars: Baron Larrey's experience

ObjectivesConsidered as the most famous French military surgeon, Dominique-Jean Larrey (1766–1842), who joined all the campaigns of Napoleon, wrote his memoirs and several medical articles. This paper discusses how in the Napoleonic times, Larrey dealt with neurosurgical diseases or injuries. Patients and methodsWe reviewed four main publications of Larrey published between 1812 and 1838 and analyzed the type of neurosurgical cases presented and their treatment. ResultsThese works include his practice of what we call now “neurosurgery” since most injuries described concern the skull or spine. He seemed to treat patients with humanity, integrity and perseverance. Larrey dealt with many aspects of neurosurgery, such as cranial or spinal trauma surgery, and also infectious diseases. He saw many head injuries inflicted not only by muskets or artillery, but also with spears and sabers. Unlike some others, Larrey advocated the use of trepanation in many situations as practiced, for instance, in the treatment of depressed fractures or in presence of subdural collections. On the other hand, this surgeon who saw thousands of amputees during his career did not mention the phantom limb phenomenon in his memoirs. Similarly, the issue of cerebral localizations is only mentioned in his last work, published in 1838. ConclusionsIn his work, Larrey (and all his contemporaries) dealt essentially with “cranial” surgery, as in skull fractures where the brain could potentially have been injured by bone fragments. The time for brain surgery had not come yet.

Relieving neural compression- bread and butter neurosurgery

Relieving pressure on neural structures constitutes the bulk of neurosurgical work load. We present a snapshot of 4 cases operated in Sep 2013, with varied neurological syndromes, surgical approaches and outcomes. The direction of future neurosurgery practice is hypothesised.

A cognitive engineering framework for the specification of information requirements in medical imaging: application in image-guided neurosurgery

This study proposes a framework coming from cognitive engineering, which makes it possible to define what information content has to be displayed or emphasised from medical imaging, for assisting clinicians according to their level of expertise in the domain. We designed a rating scale to assess visualisation systems in image-guided neurosurgery with respect to the depiction of the neurosurgical work domain. This rating scale was based on a neurosurgical work domain analysis. This scale has been used to evaluate visualisation modes among neurosurgeons, residents and engineers. We asked five neurosurgeons, ten medical residents and ten engineers to rate two visualisation modes from the same data (2D MR image vs. 3D computerised image). With this method, the amount of abstract and concrete work domain information displayed by each visualisation mode can be measured. A global difference in quantities of perceived information between both images was observed. Surgeons and medical residents perceived significantly more information than engineers for both images. Unlike surgeons, however, the amount of information perceived by residents and engineers significantly decreased as information abstraction increased. We demonstrated the possibility of measuring the amount of work domain information displayed by different visualisation modes of medical imaging according to different user profiles. Engineers in charge of the design of medical image-guided surgical systems did not perceive the same set of information as surgeons or even medical residents. This framework can constitute a user-oriented approach to evaluate the amount of perceived information from image-guided surgical systems and support their design from a cognitive engineering point of view.

Resident duty hour regulation and patient safety: establishing a balance between concerns about resident fatigue and adequate training in neurosurgery

Postgraduate training in medicine has been under scrutiny over the past 10 years with a major focus on physician personal health and patient safety. The culmination of a series of events led to the 80-hour work week instituted by the Accreditation Council on Graduate Medical Education in 2003. The effect this mandate has had on surgical education, and specifically training in neurological surgery, has been incompletely evaluated. Nevertheless, external pressure has prompted the Institute of Medicine to issue a new report on resident work hours and patient safety. In this report, the authors focus on the unique aspects of neurosurgical training in which physicians are trained to safely and effectively carry out complex high-risk tasks, the experience from abroad where work hours are reduced to well below 80 hours/week, and the risk that further reduction in work hours poses to the public. The authors conclude that there must be an adequate balance between the risks associated with resident fatigue and those associated with an inexperienced neurosurgical work force for public health.

Third nerve palsies without pupil involvment can still be surgical

Abstract Purpose To emphasise the importance of maintaining a high index of suspicion of a surgical cause of a partial third nerve palsy even when pupil is not involved. To highlight an unusual presentation of a pituitary tumour. Methods Case Report Results A 15 year old presented to the emergency department one evening after noticing he had a "droopy eyelid". He reported being under a lot of stress whilst revising for exams and described some occasional mild tension type headaches. Of note two weeks before this presentation he had "fainted" in the school playground, it had felt that this episode required no further investigation at the time. There was no other history ellicited. Also of note was that he denied any diplopia or visual symptoms. On presentation, he had a right sided partial ptosis. Visual acuity was normal. Both eyes were normal. On examintion of the ocular movements he had diplopia on upgaze especially in abduction. He had no past ocular or medical history. Goldmann fields were normal. When he was seen it was noted thet he was over 6 feet tall yet his parents were of average height. On discussing the case with radiologists and paediatricains great emphasis was placed by them on the lack of pupil involvement, it was then assumed therefore that it would be unlikely that there would be any brain lesion. However, he did go on to have an MRI scan the next day which revealed a large pituitary mass which protruded laterally hence the third nerve involvment. As of when this abstract was submitted he is awaiting neurosurgical work up. Conclusion Importance of high index of suspicion of surgical cause of third nerve palsyy depsite pupil involvement. To Highlight an unusual presentation of pituitary tumour

Erich Fischer-Brügge (28.12.1904-4.2.1951) - Founder of Neurosurgery at the University of Münster

In 1936, Erich Fischer-Brügge, who worked as a surgeon at the University Clinic of Münster, Westfalia, Germany, visited Wilhelm Tönnis in Würzburg, to receive neurosurgical training. He commenced his work in the field of neurosurgery in Münster from 1937. In 1938 he published a new classification of the anterior circulation of cerebral arteries in states of tumorous mass lesions. From 1939 through to the end of WW II, Tönnis and Fischer-Brügge worked closely together, mainly in the field of war surgery. After WW II, in 1949, Fischer-Brügge published another relevant clinical contribution on the "Clivuskantensyndom". He recognised the ipsilateral osseous compression of the oculomotor nerve at the sphenoidal ridge in raised intracranial pressure. Paul Sunder-Plassmann, successor of Hermann Coenen as chief of surgery at the University Clinic in 1946, inhibited Fischer-Brügge's neurosurgical work massively. After numerous unsuccessful applications for newly installed neurosurgical units, Fischer-Brügge died at the age of only 46 years.

The scope of neurosurgery for elderly people.

Patients treated by a single neurosurgeon over a period of 17 years have been reviewed in order to assess the volume and nature of neurosurgical work performed on patients aged over 65 years. Based on this data we report: (1) The age distribution of the principal neurosurgical conditions, drawing attention to those conditions which are over- and under-represented in elderly patients. (2) A steady increase in the number of patients over 65 admitted over the last 15 years. (3) The numbers and types of neurosurgical operations carried out on elderly patients at the present time compared with 10 years ago. (4) The outcome of first-time surgery for intracranial meningiomas in 144 patients analysed by age. It is clear that a large and increasing proportion of neurosurgical work is carried out on persons over the age of 65. Age by itself appears to be no bar to a good outcome after a major neurosurgical operation provided that the surgery is elective and is not accompanied by a diffuse neurological disturbance.

The SOSSUS report and its impact on neurosurgery.

The recently completed report of the Study on Surgical Services for the United States (SOSSUS) reveals several features of interest to neurosurgeons. There are approximately 2000 individuals practicing neurosurgery in the United States at the present time. Three-fourths of them are board-certified, and about 100 residents complete their training each year. Neurosurgical training rates have been increasing at six to 10 times the growth rate for the nation's population. Despite moderate variation in regional geographic distribution of practicing neurosurgeons, there is no real evidence of underserved areas. Distribution is even in communities with a population of 75,000 and greater. A critical feature of practice is that of work loads. Diagnostic studies make up a large protion of neurosurgical work, and the SOSSUS Area Studies reveal that complex operations are relatively relatively infrequent. This has serious implications regarding the maintenance of clinical competence, and in concentration sufficient clinical experience to train future generations of neurosurgeons. It is important to realize that the number of neurosurgeons now in practice is sufficient to meet the nation's needs. Selective cutbacks in training programs by approximately 20% seem to be in order, in coordination with similar cuts in other surgical specialties as well. This should be accompanied by a readjustment to a modest growth rate, approximately 1% per 5 years, in the ratio of neurosurgeons per 100,000 population. An accurate system of data collection is needed to provide the basis for future change in response to alterations in national needs.