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Background and Objectives: Evidence suggests that female neurosurgeons experience unique challenges in the workplace including lack of academic advancement, challenges with work-life balance, harassment, and discrimination. How these factors influence the gender gap in neurosurgery remains unclear. This analysis investigated gender differences in pediatric neurosurgeons in professional and nonprofessional activities and responsibilities., Methods: A survey examining professional activities, work-life balance, family dynamics, career satisfaction, and workplace discrimination and harassment was administered to 495 pediatric neurosurgeons. Response rate was 49% (n = 241)., Results: One-third of the pediatric neurosurgical workforce is female. There were no gender differences in race/ethnicity, American Board of Neurological Surgery/American Board of Pediatric Neurological Surgery certification rates, or pediatric neurosurgery fellowship completion. No gender differences were found in operative caseload, weekly hours worked, or working after 8 pm or weekends. Women took call more frequently than men ( P = .044). Men were more likely to work in academia ( P = .004) and have salary subsidization from external sources ( P = .026). Women were more likely to anticipate retirement by age 65 years ( P = .044), were less happy with call commitments ( P = .012), and worked more hours at home while off ( P = .050). Women more frequently reported witnessing and experiencing racial discrimination ( P = .008; P < .001), sexual harassment ( P = .002, P < .001), and feeling less safe at work ( P < .001). Men were more likely married ( P = .042) with 1 ( P = .004) or more children ( P = .034). Women reported significantly greater responsibility for child and domestic care ( P < .001). There were no gender differences in work-life balance, feeling supported at work, or having enough time to do things outside of work., Conclusion: Despite little difference in workload and professional responsibilities, women held more domestic responsibilities and experienced and witnessed more racial and sexual discrimination in the workplace. Surprisingly, there were no reported differences in work-life balance or feeling supported at work between genders. These findings suggest that factors unique to female neurosurgeons may contribute to continued gender disparity in the field., (Copyright © Congress of Neurological Surgeons 2024. All rights reserved.)

Background and Objectives: Middle meningeal artery embolization (MMAE) has emerged as a promising modality for chronic/subacute subdural hematoma treatment; however, consensus regarding embolization technique and embolisate has not been achieved. We thus sought to compare the efficacy of distinct MMAE techniques and embolisate., Methods: An institutional registry was reviewed to identify patients undergoing standalone MMAE for symptomatic chronic/subacute subdural hematoma. Surgical rescue rate and time preceding 50% hematoma resolution were evaluated across 3 technical groups: aggressive penetration (AP), nonaggressive penetration with proximal coil embolization (NP-PC), and nonaggressive penetration alone (NP). Effect sizes were adjusted for demographic, neurological and radiological features through multivariable logistic and Cox regression., Results: Among 117 procedures, 33.3% achieved AP, 36.8% had NP-PC, and 29.9% had NP. The rate of surgical rescue was 2.6% after AP, 9.3% for NP-PC, and 11.4% for NP. In patients not undergoing rescue surgery, 82.4% achieved hematoma resolution ≥50% at a median imaging follow-up of 56 days; AP or NP-PC were each statistically significantly associated with enhanced hematoma resolution as compared with NP (P = .02). Similarly, sensitivity analysis within medium-size hematoma and antiplatelet/anticoagulation-at-admission subgroups revealed a superiority of resolution after AP or NP-PC. A unique, comparative secondary analysis of liquid embolisate (Onyx vs n-butyl cyanoacrylate) revealed no impact on rate of surgical rescue or hematoma resolution., Conclusion: AP was associated with the lowest rate of surgical rescue, while both AP and NP-PC were associated with improved rates of hematoma resolution., (Copyright © Congress of Neurological Surgeons 2024. All rights reserved.)

Background and Objectives: Despite comprising half of medical students, women represent only 29.6% of neurosurgery applicants and 17% of residents, suggesting a "leak" in the career pipeline for women neurosurgeons. Surveys persistently show that neurosurgery programs identify United States Medical Licensing Examination (USMLE®) Step 1 score and letters of recommendation (LORs) as the most important factors in selecting applicants to interview. A previous study in neurosurgery found no differences in LORs. However, multiple studies in other specialties have demonstrated implicit gender bias in LORs, which may influence resident selection. Our objective is to evaluate neurosurgery residency LORs for evidence of implicit gender bias., Methods: Retrospective analysis of LORs for interviewed neurosurgery applicants at a single institution during the 2014 to 2020 National Residency Matching Program (NRMP®) match cycles. Letters were evaluated using Linguistic Inquiry & Word Count (LIWC) software (Pennebaker Conglomerates), and additional applicant data were obtained from candidate applications. LIWC (Pennebaker Conglomerates) output data included custom dictionary categories and terms that were analyzed using Prism 10 and Rstudio., Results: Two hundred eighteen applications were reviewed for a total of 827 letters. LIWC (Pennebaker Conglomerates) analysis showed significant differences in word count (331 vs 297, difference = 34, 95% CI: 9-61, P = .008). LORs for applicants who were men were more likely to mention Alpha Omega Alpha Honor Medical Society (1.17 vs 0.778, difference = 0.4, 95% CI: 0.13-0.67, P = .023). USMLE® Step 1 scores were significantly lower for women (241 vs 247, difference = 6, 95% CI: 2-10, P = .004). There was no significant difference between letters for men and women for all categories evaluated in the linguistic evaluation., Conclusion: LORs are vital to the neurosurgical residency application process. The data exhibit some differences between the men and women applicants but few differences in their LORs, consistent with the results of the previous neurosurgical study., (Copyright © Congress of Neurological Surgeons 2024. All rights reserved.)

Background and Objectives: As the global neurosurgical workforce expands, so do the contributions of women neurosurgeons. Recent studies highlighted pioneering women leaders in neurosurgery and provided invaluable perspectives into the proportion of women neurosurgeons in regions across the world. To provide a broad perspective of global trends, this study aims to characterize the global female neurosurgical workforce and evaluate its association with countries' economic status, broader physician workforce, and global gender gap index (GGGI)., Methods: A literature search included studies dated 2016-2023 characterizing the neurosurgical workforce. Total neurosurgeons, neurosurgeons per capita, and percent of women neurosurgeons by country were collected or calculated from available data. Countries were stratified by World Health Organization (WHO) region, World Bank economic classification, WHO physician workforce, and GGGI. Poisson regressions and Spearman correlation tests were performed to evaluate the association between each country's percent of women neurosurgeons and their economic classification, WHO physician workforce, and GGGI., Results: Neurosurgical workforce data were obtained for 210 nations; world maps were created demonstrating neurosurgeons per capita and proportion of women neurosurgeons. Africa had the fewest neurosurgeons (1296) yet highest percentage of women neurosurgeons (15%). A total of 94 of 210 (45%) countries met the minimum requirement of neurosurgeons needed to address neurotrauma. Compared with low-income countries, upper-middle-income and high-income countries had 27.5 times greater the rate of neurosurgeons per capita but only 1.02 and 2.57 times greater percentage of women neurosurgeons, respectively (P < .001). There was a statistically significant association between GGI and women neurosurgeons (P < .001) and a weak correlation between proportion of women in physician workforce and women neurosurgeons (P = .019, rho = 0.33)., Conclusion: Much progress has been made in expanding the neurosurgical workforce and the proportion of women within it, but disparities remain. As we address the global neurosurgeon deficit, improving recruitment and retention of women neurosurgeons through mentorship, collaboration, and structural support is essential., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Background: Although female neurosurgery residents are increasing, women remain underrepresented in academic leadership., Objectives: To assess academic productivity differences between male and female neurosurgery residents., Methods: We used the Accreditation Council for Graduate Medical Education records to obtain 2021-2022 recognized neurosurgery residency programs. Gender was dichotomized into male/female by male-presenting/female-presenting status. Extracted variables included degrees/fellowships from institutional websites, number of preresidency and total publications from PubMed, and h -indices from Scopus. Extraction occurred from March to July 2022. Residency publication number and h- indices were normalized by postgraduate year. Linear regression analyses were conducted to assess factors associated with numbers of in-residency publications. P < .05 was considered statistically significant., Results: Of 117 accredited programs, 99 had extractable data. Information from 1406 residents (21.6% female) was successfully collected. 19 687 and 3261 publications were evaluated for male residents and female residents, respectively. Male and female residents' median preresidency publication numbers did not significantly differ (M:3.00 [IQR 1.00-8.50] vs F:3.00 [IQR 1.00-7.00], P = .09), nor did their h -indices. However, male residents had significantly higher median residency publications than female residents (M:1.40 [IQR 0.57-3.00] vs F:1.00 [IQR 0.50-2.00], P < .001). On multivariable linear regression, male residents (odds ratio [OR] 2.05, 95% CI 1.68-2.50, P < .001) and residents with more preresidency publications (OR 1.17, 95% CI 1.16-1.18, P < .001) had higher likelihood of publishing more during residency, controlling for other covariates., Conclusion: Without publicly available, self-identified gender designation for each resident, we were limited to review/designate gender based on male-presenting/female-presenting status from gender conventions of names/appearance. Although not an ideal measurement, this helped show that during neurosurgical residency, male residents publish significantly more than female counterparts. Given similar preresidency h- indices and publication records, this is unlikely explained by differences in academic aptitude. In-residency gender barriers to academic productivity must be acknowledged and addressed to improve female representation within academic neurosurgery., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Background: Current treatment guidelines for clival chordomas recommend surgical resection followed by high-dose radiotherapy (RT). However, in patients in whom gross total resection (GTR) is achieved, the benefits of additional RT remain unclear., Objective: To investigate whether RT offers any benefit to progression-free survival (PFS) in patients undergoing GTR of clival chordoma by performing a systematic review of all currently published literature., Methods: A total of 5 databases were searched to include all studies providing data on GTR ± RT for clival chordomas (January 1990-June 2021). Qualitative assessment was performed with Newcastle-Ottawa Scale guidelines for assessing quality of nonrandomized studies. Statistical analysis using individualized patient data of PFS was performed., Results: The systematic search yielded 2979 studies, weaned to 22 full-text articles containing 108 patients. All patients underwent GTR of clival chordoma, with 46 (43%) patients receiving adjuvant RT. Mean PFS for RT patients was 31.09 months (IQR: 12.25-37.75) vs 54.92 months (IQR: 14.00-85.75) in non-RT patients. Overall, RT did not increase PFS (HR 0.320, P = .069) to a value that achieved statistical significance. Stratifying by photon therapy vs particle beam therapy yielded no statistically significant benefit for particle beam therapy for PFS ( P = .300). Of patients with age ≥65 years, RT did not improve outcomes to statistical significance for PFS (HR 0.450, P = .481). Patients age ≥65 years had lower PFS on both bivariate analysis (HR 3.708, P = .007) and multivariate analysis (HR 3.322, P = .018)., Conclusion: After achieving GTR of clival chordoma, fractionated RT offers unclear benefit upon survival outcomes., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)