Prior large-scale multicountry studies of traumatic brain injury (TBI) have either focused on surgically managed patients across development settings or characterized the full case-mix in predominantly high-income regions, leaving operative and nonoperative TBI across the human development spectrum incompletely defined. We present the Global Neurosurgical Study-1, integrating operative and nonoperative TBI across all Human Development Index (HDI) tiers. This prospective cohort included 2,165 patients from 100 hospitals in 29 countries between 2019 and 2022. Disparities were noted: median age ranged from 32 years (high-HDI) to 63 years (very-high-HDI); traffic injuries were the predominant cause of TBI in low-HDI (65.8%) versus falls in very-high-HDI (66%); and 69.3% of patients in the low-HDI tier arrived via private vehicles versus 13% for the very-high-HDI tier. Using mixed-effects logistic regression with inverse probability weighting, the adjusted mortality odds were highest in high-HDI tier (odds ratio 3.13, 95% confidence intervals 1.12-8.78) relative to the very-high-HDI, with no statistically significant elevation in low- or medium-HDI tiers. No dose-response relationship was noted between mortality and HDI. Inequities in injury mechanisms, patient demographics and prehospital access were drivers of outcome disparities. These findings suggest that HDI-stratified prevention targeting injury mechanisms and prehospital care may reduce the global TBI burden more effectively than hospital-based measures alone.

Although primary studies have reported the safety and efficacy of LITT as a primary treatment in glioma, they are limited by sample sizes and institutional variation in stereotactic parameters such as temperature and laser power. The current literature has yet to provide pooled statistics on outcomes solely for primary brain tumors according to the 2021 WHO Classification of Tumors of the Central Nervous System (WHO CNS5). In the present study, we identify recent articles on primary CNS neoplasms treated with LITT without prior intervention, focusing on relationships with molecular profile, PFS, and OS. This meta-analysis includes the extraction of data from primary sources across four databases using the Covidence systematic review manager. The pooled data suggest LITT may be a safe primary management option with tumor ablation rates of 94.8% and 84.6% in IDH-wildtype glioblastoma multiforme (GBM) and IDH-mutant astrocytoma, respectively. For IDH-wildtype GBM, the pooled PFS and OS were 5.0 and 9.0 months, respectively. Similar to rates reported in the prior literature, the neurologic and non-neurologic complication rates for IDH-wildtype GBM were 10.3% and 4.8%, respectively. The neurologic and non-neurologic complication rates were somewhat higher in the IDH-mutant astrocytoma cohort at 33% and 8.3%, likely due to a smaller cohort size.

OBJECTIVE:The cerebral and spinal venous systems have similar functions but unique anatomical and physiological properties. CSF occupies space in the cranial and spinal vaults, is continuously produced, and has many roles, including maintaining a favorable environment for CNS structures. The influence of the cerebrospinal venous system on CSF dynamics has been theorized since the 1940s. Newer studies suggest venous outflow pattern alterations in response to changes in body position. However, the relationship of postural cerebrospinal venous outflow shifts with and their influence on CSF homeostasis is not well understood. METHODS:The authors searched the published literature related to the anatomy and function of vertebral venous plexus (VVP), CSF, and positional cerebral venous flow characteristics. A comprehensive collection of literature was compiled and reviewed, and the relationship between cerebrospinal and venous system changes and alterations in body positions, with an emphasis on the craniocervical system, is discussed. RESULTS:The VVP is a network of valveless veins extending from the sacrum to the cranium that are interconnected with the cranial dural sinuses. The internal VVP occupies space within the extradural spinal canal and functions to return spinal venous blood to the heart, but it has additional properties, including the capability of bidirectional venous flow, an intraspinal dilatory capacity, and a role in cerebral venous outflow. When one rises to the upright position, CSF shifts toward the spinal canal and force vectors change, leading to reduced intracranial CSF pressure; simultaneously, cerebral venous outflow shifts from the jugular vein to the VVP outflow pathway. The venous outflow shift mechanism and its purpose are poorly understood. The authors review the known physiology of the system, identify gaps in knowledge to direct future research, and propose an interpretation of these data, concluding that position-dependent CSF and cerebrospinal venous shifts are part of a complementary positional craniospinal pressure regulation system that must be kept in balance for optimal CNS function. CONCLUSIONS:Current knowledge of the cerebrospinal venous anatomy, dynamic flow characteristics in response to gravity, and the venous system's influence on CSF suggests that the VVP plays a role in influencing CSF pressure, and the authors hypothesize that it plays a role in supporting intracranial pressure in the upright body posture. Further research is needed to better characterize the functional relationship of the VVP to CSF dynamics as well as identify potentially related disease states.

The rise in availability of neuroimaging has led to an increase in incidentally discovered meningiomas. These tumors are typically asymptomatic and tend to display slow growth. Treatment options include observation with serial monitoring, radiation, and surgery. Although optimal management is unclear, clinicians recommend a conservative approach, which preserves quality of life and limits unnecessary intervention. Several risk factors have been investigated for their potential utility in the development of prognostic models for risk assessment. Herein, the authors review the current literature on incidental meningiomas, focusing their discussion on potential predictive factors for tumor growth and appropriate management practices.

Introduction: While spinal cord stimulation (SCS) has been shown to be safe and effective for treatment of chronic back and leg pain, it is not offered to geriatric patients as frequently as it is to their younger counterparts. In this study, we examine SCS outcomes in older patients to determine whether SCS is a plausible safe treatment in this age group.Material & Methods: We retrospectively identified 26 patients aged 80 or older who underwent thoracic SCS with a single neurosurgeon over a 5-year period and recontacted them to complete a survey regarding their experience. Survey responses, demographics, and complicating surgical factors were collected and summary statistics generated.Results: Our response rate was 77% (20/26). Respondents averaged 83.6 years with a slight female preponderance (12/20, 60%). Most had two or more medical comorbidities. Only 2 (10%) experienced postoperative complications, neither requiring reoperation. Sixteen respondents (80%) were still using their stimulators, with 13 (65%) experiencing at least 50% pain relief. Fourteen of 20 patients (70%) would have SCS surgery again, and the same fraction would recommend it to a friend. Most respondents endorsed a good understanding of their devices (18/20, 90%).Conclusions: Octogenarians experienced improvement in chronic back and/or leg pain following SCS on par with pain relief observed in their younger counterparts. Further, they experienced only minor postsurgical complications despite having typical comorbidities. Based on these findings, SCS should be considered as a safe and effective treatment option for geriatric patients with refractory back and/or leg pain.

The gap between the tremendous burden of neurological disease requiring surgical management and the limited capacity for neurosurgical care has fueled the growth of the global neurosurgical movement. It is estimated that an additional 23 300 neurosurgeons are needed to meet the burden posed by essential cases across the globe. Initiatives to increase neurosurgical capacity through systems strengthening and workforce development are key elements in correcting this deficit. Building on the growing interest in global health among neurosurgical trainees, we propose the integration of targeted public health education into neurosurgical training, in both high-income countries and low- and middle-income countries. This effort will ensure that graduates possess the fundamental skillsets and experience necessary to participate in and lead capacity-building efforts in the developing countries. This additional public health training can also help neurosurgical residents to achieve the core competencies outlined by accreditation boards, such as the Accreditation Committee on Graduate Medical Education in the United States. In this narrative review, we describe the global burden of neurosurgical disease, establish the need and role for the global neurosurgeon, and discuss pathways for implementing targeted global public health education in the field of neurosurgery.

-OBJECTIVE: We examined the role of intrawound vancomycin powder as prophylaxis against postoperative surgical site infection (SSI) after spinal cord stimulator (SCS) implantation. -METHODS: We performed a retrospective analysis of 153 consecutive patients who had undergone permanent SCS implantation surgery via open laminectomy between 2014 and 2020. We queried the patients' medical records for patient age, sex, relevant medical history, and whether intrawound vancomycin had been administered. We compared the rates of SSI (primary outcome) and seroma (secondary outcome) within 3 months after surgery between the vancomycin and no-vancomycin groups. Finally, we conducted multivariable logistic regression analyses to identify independent predictors of postoperative SSI or seroma. -RESULTS: Of the 153 patients, 59% were women, and the average age was 65.4 years. Overall, 3 patients (2%) had developed an SSI: 2 (methicillin-resistant Staphylococcus aureus, Klebsiella) in the vancomycin group and 1 (methicillin-sensitive Staphylococcus aureus) in the novancomycin group. This difference in SSI rate between the 2 groups was insignificant (P = 0.73). Three seromas, all in the no-vancomycin group, accounted for a statistically significant difference in seroma formation between the 2 groups (P = 0.04). Multivariate logistic regression failed to identify any perioperative characteristics as independent predictors of postoperative SSI or seroma. -CONCLUSIONS: Our experience suggests open laminectomy for SCS implantation surgery can be performed with a low postoperative SSI rate, with or without the use of powdered vancomycin. We found no evidence suggesting that the use of powdered vancomycin is unsafe or related to postoperative seroma formation. We failed to draw any definitive conclusions regarding its efficacy, despite referencing the largest single case series of SCS implantation to date.

Abstract Globally, traumatic brain injury (TBI) affects 69 million individuals every year. However, there are wide variations in the management of TBI across low-, middle- and high-income countries which reflects on the outcomes of TBI worldwide. This study aims to provide a comprehensive global picture of the surgical and nonsurgical management and outcomes of TBI. The Global NeuroSurg 1 study is a prospective international multicentre cohort study conducted in self-selected registered centers. Any hospital receiving and managing TBI patients is eligible to participate (registration through www.globalneurosurg.org). After obtaining institutional ethical approvals, collaborator teams collect consecutive TBI patient data within any 2 weeks from the 1 June 2019 to the 30 September 2021 with 90 days of follow-up for every patient. Data items include (1) patient demographics, (2) TBI timing, severity and mechanism, (3) clinical status of the patient, (4) radiographic findings, (5) surgical and nonsurgical management and (6) patient survival and Glasgow outcome score. All data are submitted to the secure RedCap system of Oregon Health and Science University, OR. Binary logistic regression analysis will be conducted to evaluate the predictors of 30-day mortality. The odds ratios and the corresponding 95% confidence intervals will be calculated for each variable. Then variables that are independently contributing to the mortality will be selected and examined. Study ethical approvals or ethical approval waivers are obtained from all participating centers. All collected data are kept confidential and will be used only for the purpose of this study.

To the Editor: We read with great interest the article by Atli et al,1 which highlights virtual reality as a means to modernizing neurosurgical education. We believe this article is of profound academic importance and aim to present an additional valuable resource in neurosurgery for current and aspiring medical students. Here, we discuss the evolution of the various online platforms within organized neurosurgery throughout the 21st century. As a resident at the University of Maryland, Dr Mark Iguchi initiated in 2006 the first such platform through NS Match, calling it Neurosurgery Online. This site was short lived as it did not possess the infrastructure to sustain interest from medical students and young surgeons alike. However, it did highlight the need for a platform wherein current and aspiring neurosurgeons could engage and learn from seasoned attendings and medical students could find resources on things like navigating the neurosurgery match. In 2007, Dr Kenneth Liu, a resident at the University of Oregon, helped to fill these gaps with the platform Uncle Harvey. The original Uncle Harvey allowed students to engage across the spectrum of neurosurgery with residents, fellows, attendings, and peers. Each forum within Uncle Harvey helped cover a distinct topic within neurosurgery, with the addition of space for case presentations from leaders in the field. By 2012, Uncle Harvey fell in the ranks following a perceived plateau in usership. That same year, a similar yet lesser known platform, Legacy NsgyApplicants, served as the only online neurosurgical forum available for the next 3 yr. By 2015, however, resources from Legacy NsgyApplicants were no longer accessible. In 2016, a resident at the University of Buffalo picked up the baton and created Neurosurgery Hub. Neurosurgery Hub broadcasted to a wider audience and contained separate forums for students, residents, fellows, and attendings on both the national and international scales. It offered a unique space for discussing interesting cases, providing easy-access resource links, and publishing employment listings. Unlike its predecessors, Neurosurgery Hub content was accessible without registration. In 2020, a student-led initiative sought to join forces with the original creator of Neurosurgery Hub to distill the best parts of the site, along with those of its predecessors, into the new and improved Uncle Harvey 2.0. The revised Uncle Harvey maintained the forums, resources, and job listings seen previously, but added forum moderation, a blog, research opportunities, a YouTube channel, and an expanded residency program review functionality in an effort to provide a “one-stop shop” for all of neurosurgery. The field of neurological surgery in America blossomed in the early 20th century largely due to the pioneering work of the esteemed Harvey Williams Cushing (1869-1939).2 Much in the world has changed since Cushing's time, though perhaps nothing more dramatically than the rapid evolution of technology. With these changes have come great advancements in our capacity to preserve our history as a surgical specialty, to promote far-reaching global interest in neurosurgery, and to remain more interconnected than ever before.3 Organized neurosurgery has consistently sought new and innovative ways to take advantage of the opportunities this newfound era has provided. As both neurosurgery and technology continue to evolve, online neurosurgery platforms have proven capable of adapting to these changes while continuing to serve the community at large. Funding This study did not receive any funding or financial support. Disclosures The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.

Nugent, Joseph G; Stedelin, Brittany; Teton, Zoe E BS; Siler, Dominic A MD, PhD; Motika, Paul; Cetas, Justin S MD, PhD; Zonies, David; Schreiber, Martin MD; Raslan, Ahmed M.T Author Information

OBJECTIVE The advent of the internet and the popularity of e-learning resources has promoted a shift in medical and surgical education today. The Neurosurgical Atlas has sought to capitalize on this shift by providing easily accessible video and online education to its users on an international scale. The rising popularity of social media has provided new avenues for expanding that global reach, and the Atlas has sought to do just that. In this study, the authors analyzed user demographics and web traffic patterns to quantify the international reach of the Atlas and examined the potential impact of social media platforms on the expansion of that reach. METHODS Twitter, Facebook, and Instagram metrics were extracted using each respective service's analytics tool from the date of their creation through October 2019. Google Analytics was used to extract website traffic data from September 2018 to September 2019 and app data from January 2019 to October 2019. The metrics extracted included the number of platform users/followers, user demographic information, percentage of new versus returning visitors, and a number of platform-specific values. RESULTS Since the authors' previous publication in 2017, annual website viewership has more than doubled to greater than 500,000 viewing sessions in the past year alone; international users accounted for more than 60% of the visits. The Atlas Twitter account, established in August 2012, has more than 12,000 followers, primarily hailing from the United States, the United Kingdom, Canada, and Saudi Arabia. The Atlas Facebook account, established in 2013, has just over 13,000 followers, primarily from India, Egypt, and Mexico. The Atlas Instagram account (established most recently, in December 2018) has more than 16,000 followers and the highest percentage (31%) of younger users (aged 18-24 years). The Atlas app was officially launched in May 2019, largely via promotion on the Atlas social media platforms, and has since recorded more than 60,000 viewing sessions, 80% of which were from users outside the United States. CONCLUSIONS The Neurosurgical Atlas has attempted to leverage the many e-learning resources at its disposal to assist in spreading neurosurgical best practice on an international scale in a novel and comprehensive way. By incorporating multiple social media platforms into its repertoire, the Atlas is able to ensure awareness of and access to these resources regardless of the user's location or platform of preference. In so doing, the Atlas represents a novel way of advancing access to neurosurgical educational resources in the digital age.

BACKGROUND: Hemifacial spasm (HFS) is a debilitating disorder characterized by intermittent involuntary movement of muscles innervated by the facial nerve. HFS is caused by neurovascular compression along the facial nerve root exit zone and can be treated by microvascular decompression (MVD). The goal was to determine rates and predictors of spasm freedom after MVD for HFS. METHODS: A literature search using the key terms "microvascular decompression" and "hemifacial spasm" was performed. The primary outcome variable was spasm freedom at last follow-up. Analysis was completed to evaluate for variables associated with spasm-free outcome. RESULTS: A total of 39 studies including 6249 patients were analyzed. Overall spasm freedom rate was 90.5% (5652/6249) at a follow-up of 1.25 +/- 0.04 years. There was no significant relationship between spasm freedom versus persistent spasm and age at surgery, timing of follow-up, gender, disease duration, side of disease, or vessel type. Spasm freedom was more likely after an initial surgery versus a redo MVD (odds ratio 4.16, 95% confidence interval 1.99-8.68; P < 0.01). CONCLUSIONS: MVD works well for HFS with cure rates >90% at 1-year follow-up in 6249 patients from 39 studies. A significant predictor of long-term spasm freedom at 1 year was an initial MVD as compared to repeat MVD. The majority of published manuscripts on MVD for HFS are heterogeneous single-institutional retrospective studies. As such, a large-scale meta-analysis reporting outcome rates and evaluating significant predictors of spasm freedom provides utility in the absence of randomized controlled studies.

Motor cortex stimulation (MCS) has been used in the treatment of intractable neuropathic facial pain for nearly 30 years. While efficacy rates have been noted as high as 88% in some studies, considerable variability in treatment response remains. Additionally, MCS is often cited as providing diminishing relief over time, and there are few long-term studies on efficacy. Complications are generally mild and include infection, hardware complication, seizure, and transient neurological deficit. Despite relatively minimal use, MCS remains a viable treatment option for the appropriately selected facial pain patients that have proved refractory to conservative management.

OBJECTIVE Common interbody graft options for anterior cervical discectomy and fusion (ACDF) include allograft and polyetheretherketone (PEEK). PEEK has gained popularity due to its radiolucent properties and a modulus of elasticity similar to that of bone. PEEK devices also result in higher billing costs than allograft, which may drive selection. A previous study found a 5-fold higher rate of pseudarthrosis with the use of PEEK devices compared with structural allograft in single-level ACDF. Here the authors report on the occurrence of pseudarthrosis with PEEK devices versus structural allograft in patients who underwent multilevel ACDF. METHODS The authors retrospectively reviewed 81 consecutive patients who underwent a multilevel ACDF and had radiographic follow-up for at least 1 year. Data were collected on age, sex, BMI, tobacco use, pseudarthrosis, and rate of reoperation for pseudarthrosis. Logistic regression was used for data analysis. RESULTS Of 81 patients, 35 had PEEK implants and 46 had structural allograft. There were no significant differences between age, sex, smoking status, or BMI in the 2 groups. There were 26/35 (74%) patients with PEEK implants who demonstrated radiographic evidence of pseudarthrosis, compared with 5/46 (11%) patients with structural allograft (p < 0.001, OR 22.2). Five patients (14%) with PEEK implants required reoperation for pseudarthrosis, compared with 0 patients with allograft (p = 0.013). CONCLUSIONS This study reinforces previous findings on 1-level ACDF outcomes and suggests that the use of PEEK in multilevel ACDF results in statistically significantly higher rates of radiographic pseudarthrosis and need for revision surgery than allograft. Surgeons should consider these findings when determining graft options, and reimbursement policies should reflect these discrepancies.

In this installment of the Neurosurgical Atlas Series for WORLD NEUROSURGERY, the authors examine the paramedian supracerebellar transtentorial (SCTT) approach as a means of accessing the basal posteromedial temporal lobe for both intradural and extradural lesions. While other approaches, such as the subtemporal, transtemporal, and transsylvian routes, are often used to reach this otherwise impervious region, all of them do so at the expense of supratentorial structural integrity. Despite the long and narrow working distance provided by the SCTT approach, the access it provides to critical, deep-seated regions with little to no associated morbidity makes it our preferred approach in these patients. In this work, we highlight the perioperative considerations for this procedure, discuss the technical nuances of all aspects of the operation, and provide discussion on the approach in the context of its evolution and alternatives.

Chronic pain is one of the most pervasive, debilitating, and expensive conditions encountered by healthcare professionals and faced by patients. Chronic pain treatment is highly varied, increasingly complex, and challenging to healthcare providers. The neurosurgeon possesses a unique set of tools to treat chronic pain, especially when other modalities have failed: neuromodulation. In this chapter the most commonly utilized neuromodulatory techniques are highlighted, and a discussion of efficacy rates, clinical indications, and complications is provided.

Background Every year, there are about sixty-nine million new cases of Traumatic Brain Injury (TBI) worldwide. However, there are wide variations in the management of TBI across low-, middle-, and high-income countries which affect TBI outcomes worldwide. Aim This study aims to provide a comprehensive global picture of the management and outcomes of TBI in high-, middle-, and low-income countries. Objectives Primary objectives To determine the mortality rates after TBI in low-, middle-, and high-income countries. To determine the functional outcomes after TBI in low-, middle-, and high-income countries. Secondary objectives To compare the mortality rates of TBI in HICs vs. LMICs. To compare the functional outcomes of TBI in HICs vs. LMICs. To determine the factors associated with mortality following TBI. To determine the pattern of TBI management in low-, middle-, and high-income countries. To determine TBI associated complications. To form of an international network of neurosurgery researchers to facilitate future research efforts. Study Design A multicenter, international, prospective cohort study Duration One year (from the 1st of June 2019 to the 31st of May 2020) Follow up: 90 days Study Setting The study will be conducted in self-selected registered centers worldwide. Any hospital receiving and managing TBI patients is eligible to participate in Global NeuroSurg-1; There is no minimum patient number per center; all consecutive cases must be included. Eligibility Criteria The study will include TBI patients who meet the following criteria: [1] TBI defined as WHO ICD-11 codes from NA07.0 to NA07.9. [2] patients with mild, moderate, and severe TBI [3] Age ≥18 years old [4] both genders Data Collection Method We will collect anonymous data on patient demographics, TBI etiology and severity, clinical and surgical management, and the 30-day and 90-day mortality rate. All data will be submitted to the secure Redcap system of the Oregon Clinical & Translational Research Institute, Oregon Health and Science University. Sample Size A total sample size of 1153 patients will allow detecting a mortality rate of 25% with a 5% wide 95% confidence interval. The sample size was calculated using R software version 3.4.1 (The R Foundation for Statistical Computing). Statistical analysis plan The human development index (HDI) is a composite score of life expectancy, education, and income indices published by the United Nations (http://hdr.undp.org/en/statistics). Participating centers will be classified into three tertiles according to the HDI rank. We will test the differences between HDI tertiles by using the Pearson chi-square test for categorical variable and Kruskal–Wallis test for continuous variables. Binary logistic regression analysis will be conducted to evaluate the predictors of 30-day mortality. The odds ratios (OR) and the corresponding 95% confidence intervals will be calculated for each variable. First, variables from the univariate analysis with P˂0.05 will be selected for inclusion in the multivariate model. Then variables that are independently contributing to the mortality will be selected and examined. All analyses will be conducted by STATA software (version 15) for windows. Ethics and dissemination Study ethical approval will be acquired from all participating centers. All collected data will be kept confidential and will be used only for this study.

Abstract Temporal lobe epilepsy (TLE) is the most common form of adult localization-related epilepsy and 80% of these cases originate in the hippocampus. Hippocampal sclerosis (HS) is the single most common cause of medically refractory epilepsy that is also amenable to surgery and is a combination of astrogliosis and atrophy throughout the hippocampus. HS is both a cause and result of seizures originating in this region and is among the least likely seizure disorders to be cured by medical treatment alone. Selective amygdalohippocampectomy (SAHC) has been shown to have comparable rates of seizure freedom to anterior temporal lobectomy (ATL) with fewer neurocognitive side effects. Complications include visual field deficits, ischemia, and neurocognitive decline, most commonly in verbal memory.