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Introduction: Reports about lateral lumbar or thoracic interbody fusion (LLIF) using expandable interbody spacers are sparse., Research Question: To report our experience with the use of expandable spacers for LLIF., Material and Methods: We reviewed all consecutive LLIF patients with use of an expandable titanium interbody implant (ELSA® Expandable Integrated LLIF Spacer, Globus Medical Inc, PA (USA)) between September 2018 and January 2024., Results: We identified 503 patients, in which we performed LLIF at 732 levels. In 63 patients (12.5%) and 70 levels (9.6%) an expandable spacer was used. The mean age was 61.4 years, 57.1% were females. LLIF was performed between T11/12 - L4/5 in the setting of fusion procedures (mono-/bisegmental (20; 28.6%), 3-7 segments (29; 41.4%); >7 segments (21; 30.0%)), of which 21 (33.3%), 20 (31.8%) and 22 (34.9%) were for traumatic, deformity/revision and other diagnoses. Surgery included release of the anterior longitudinal ligament in 30 cases (42.9%). Intraoperative adverse events (AEs) were noted in 2 (3.2%), postoperative AEs in 27 (42.9%) at discharge, 17 (27.0%) at 3 months and 14 (22.2%) at 12 months. Segmental sagittal Cobb angle changed from 1.3° (preoperative) to 13.0° at discharge (p < 0.001), 12.7° at 3 months (p < 0.001) and 13.3° at 12 months (p < 0.001). Functional outcome was excellent/good in 43 (68.3%; 5 missing) at 3 months and in 37 (58.7%; 10 missing) at 12 months., Discussion and Conclusion: The use of LLIF with an expandable spacer was safe, promoted solid fusion and enabled powerful correction of sagittal segmental Cobb angle, which was maintained during follow-up., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Martin N. Stienen reports financial support was provided by Globus Medical. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Introduction: Cystic schwannomas have only been reported in a few case reports/series. As a result, they may be misdiagnosed and a standardized management approach remains challenging to establish., Research Question: The aim of this study was to compile all reported cases of cystic schwannomas and analyze the perioperative course based on a systematic review of the literature with an additional two cases from the authors' experience., Material and Methods: We conducted a search of MEDLINE and CENTRAL databases for spinal intradural extramedullary cystic schwannomas, in accordance to the PRISMA statement. All title/abstracts were screened, and a full-text review of the remaining articles was conducted. The results were compiled in tables and summarized using means and standard deviation (SD), median and interquartile range, and percentage and 95% confidence intervals., Results: We identified 263 articles, of which 35, which reported 54 cases, were included. Including our case-reports (n = 56), patients had a mean age of 47.7 years (SD ± 13.0 years) at presentation, 57% were males, and most lesions were lumbar (43%). The most common symptoms were pain (82%) and muscle weakness (68%) with 84% of patients showing neurological findings. 70% of patients showed a complete relief of symptoms after surgery and 96% reported improvement. Only four complications were reported., Discussion and Conclusion: Schwannomas should be considered in the differential diagnosis of intradural extramedullary cystic lesions. Patients typically present with subacute to chronic pain and/or neurologic changes. Surgical resection is the primary therapeutic modality and usually has a good to excellent outcome., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Introduction: Imposter syndrome (IS), characterized by persistent doubts about one's abilities and fear of exposure as a fraud, is a prevalent psychological condition, particularly impacting physicians. In neurosurgery, known for its competitiveness and demands, the prevalence of IS remains high., Research Question: Recognizing the limited literature on IS within the neurosurgical community, this European survey aimed to determine its prevalence among young neurosurgeons and identify associated factors., Material and Methods: The survey, conducted by the Young Neurosurgeon Committee of the European Association of Neurosurgical Societies, gathered responses from 232 participants. The survey included demographics, the Clance Imposter Phenomenon Survey (CIPS), and an analysis of potential compensatory mechanisms., Results: Nearly 94% of respondents exhibited signs of IS, with the majority experiencing moderate (36.21%) or frequent (40.52%) symptoms. Analyses revealed associations between IS and factors such as level of experience, sex, and board-certification., Discussion and Conclusion: The findings suggest a significant prevalence of IS among young neurosurgeons, with notable associations with sex and level of experience. Compensatory mechanisms, such as working hours, article reading, and participation in events, did not show significant correlations with IS. Notably, male sex emerged as an independent protective factor against frequent/intense IS, while reading more than five articles per week was identified as a risk factor. The identification of protective and risk factors, particularly the influence of gender and reading habits, contributes valuable insights for developing targeted interventions to mitigate IS and improve the well-being of neurosurgeons., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Introduction: Artificial intelligence (AI) based large language models (LLM) contain enormous potential in education and training. Recent publications demonstrated that they are able to outperform participants in written medical exams., Research Question: We aimed to explore the accuracy of AI in the written part of the EANS board exam., Material and Methods: Eighty-six representative single best answer (SBA) questions, included at least ten times in prior EANS board exams, were selected by the current EANS board exam committee. The questions' content was classified as 75 text-based (TB) and 11 image-based (IB) and their structure as 50 interpretation-weighted, 30 theory-based and 6 true-or-false. Questions were tested with Chat GPT 3.5, Bing and Bard. The AI and participant results were statistically analyzed through ANOVA tests with Stata SE 15 (StataCorp, College Station, TX). P-values of <0.05 were considered as statistically significant., Results: The Bard LLM achieved the highest accuracy with 62% correct questions overall and 69% excluding IB, outperforming human exam participants 59% (p = 0.67) and 59% (p = 0.42), respectively. All LLMs scored highest in theory-based questions, excluding IB questions (Chat-GPT: 79%; Bing: 83%; Bard: 86%) and significantly better than the human exam participants (60%; p = 0.03). AI could not answer any IB question correctly., Discussion and Conclusion: AI passed the written EANS board exam based on representative SBA questions and achieved results close to or even better than the human exam participants. Our results raise several ethical and practical implications, which may impact the current concept for the written EANS board exam., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Introduction: Preoperative embolization (PE) for spinal metastasis can be used to reduce tumor blood supply in selected patients. The decision whether and when to perform PE varies largely among spine surgeons and centers., Research Question: The aim was to understand the current decision-making process in European spine centers., Material and Methods: The European Association of Neurosurgical Societies (EANS) spine section designed a 13-item online survey. It was distributed to neurosurgical residents and board-certified neurosurgeons between 7th of February and May 5, 2023., Results: We analyzed 120 survey responses. Most participants were board-certified neurosurgeons (71%) or residents (26%) in university hospitals (76%). Routinely performed PE was stated not a common practice in 62%. Of those using PE, 25% indicated to perform it in selected cases requiring vertebral body replacement. Reasons for not performing PE included lack of time (44%), unclear benefits (25%), no significant bleeding without PE (19%), and significant bleeding despite PE (8%). Most participants opted for PE < 24h before surgery, but in a separate anesthesia (54%). More experienced participants were more likely to observe reduced blood loss (BL) after PE (p = 0.014). The most common reported complications were neurological deterioration due to spinal cord infarction (n = 15) and swelling due to tumor necrosis (n = 13)., Discussion and Conclusions: PE is still not a routine among European spine surgeons and is considered mostly for elective cases with hypervascularized tumors scheduled in a separate anesthesia <24h before tumor resection. Most participants noted reduced intraoperative BL, but also a risk of procedure-related complications., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

Introduction: Technological advancements provided several preoperative tools allowing for precise preoperative planning in cranial neurosurgery, aiming to increase the efficacy and safety of surgery. However, little data are available regarding if and how young neurosurgeons are trained in using such technologies, how often they use them in clinical practice, and how valuable they consider these technologies., Research Question: How frequently these technologies are used during training and clinical practice as well as to how their perceived value can be qualitatively assessed., Materials and Methods: The Young Neurosurgeons' Committee (YNC) of the European Association of Neurosurgical Societies (EANS) distributed a 14-items survey among young neurosurgeons between June 1st and August 31st , 2022., Results: A total of 441 responses were collected. Most responders (42.34%) received "formal" training during their residency. Planning techniques were used mainly in neuro-oncology (90.86%), and 3D visualization of patients' DICOM dataset using open-source software was the most frequently used (>20 times/month, 20.34% of responders). Software for 3D visualization of patients' DICOM dataset was the most valuable technology, especially for planning surgical approach (42.03%). Conversely, simulation based on augmented/mixed/virtual reality was considered the less valuable tool, being rated below sufficiency by 39.7% of responders., Discussion and Conclusion: Training for using preoperative planning technologies in cranial neurosurgery is provided by neurosurgical residency programs. Software for 3D visualization of DICOM datasets is the most valuable and used tool, especially in neuro-oncology. Interestingly, simulation tools based on augmented/virtual/mixed reality are considered less valuable and, therefore, less used than other technologies., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Jiri Bartek Jr reports a relationship with Medtronic Inc that includes: consulting or advisory., (© 2023 The Authors.)

Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Introduction: Modern technologies are increasingly applied in neurosurgical resident training. To date, no data are available regarding how frequently these are used in the training of neurosurgeons, and what the perceived value of this technology is., Research Question: The aim was to benchmark the objective as well as subjective experience with modern- and conventional training technologies., Material and Methods: The EANS Young Neurosurgeons Committee designed a 12-item survey. It was distributed to neurosurgical residents and board-certified neurosurgeons between 6th of February and April 13, 2022., Results: We considered 543 survey responses for analysis. Most participants (67%) indicated not having gained any training experience with modern technology. Most (40.7%) indicated lack of any modern or conventional training technology. Cadaver training was available to 27.6% while all modern training technology to <10%. Participants from countries with high gross domestic product per capita had more access to modern training technologies (p ​< ​0.001). The perceived value of the different technologies was highest for hands-on OR training, followed by cadaver lab. The value of these was rated higher, compared to all modern technologies (p ​< ​0.001)., Discussion and Conclusion: Our survey reveals that cadaver labs are used more frequently than modern technologies for today's neurosurgical training. Hands-on training in the operating room (OR) was rated significantly more valuable than any conventional and modern training technology. Our data hence suggest that while modern technologies are well perceived and can surely add to the training of neurosurgeons, it remains critical to ensure sufficient OR exposure., (© 2022 Published by Elsevier B.V. on behalf of EUROSPINE, the Spine Society of Europe, EANS, the European Association of Neurosurgical Societies.)

•The TUG test and the 6WT are feasible to apply in ambulatory patients with spinal cord affection.•The objective measurement of functional impairment resembled the functional status of four patients in this pilot study.•The TUG test and the 6WT may detect and quantify functional decline and/or improvement resulting from spinal cord affection.•Modern smartphone app-based technology may help to accurately quantify impairment, which is key for decision-making and evaluating the efficacy of interventions., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Authors.)

Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Jiri Bartek reports a relationship with Medtronic that includes: consulting or advisory.

Introduction: Women continue to be underrepresented in the majority of surgical specialties, including neurosurgery., Research Question: In this multinational survey, we aimed to assess current gender disparities in neurosurgery focusing on job satisfaction and inequity/discrimination at work., Material and Methods: Female and male members of the European Association of Neurosurgical Societies were asked to complete an electronic survey (Google Forms, Mountain View) containing demographic baseline data and questions on attitudes regarding gender disparity, personal experience with gender inequity and career satisfaction/work-life balance. Quantitative analyses were performed to analyse the responses, including summary and comparative statistics., Results: We received 168 responses from 40 different countries. Survey responders had a mean age of 40.8 ​± ​11.5 years; 29.8% were female. There were significant more male than female residents and attending surgeons per department. Eighty-eight percent of female and 38.1% of male responders experienced gender inequity or discrimination at work (adjusted OR 10.8, 95%CI 4.2-27.8, p <0.001). Female neurosurgeons were more likely to be discriminated by colleagues (aOR 4.32, 95%CI 2.1-9.1, p <0.001) and by patients/relatives (aOR 3.65, 95%CI 1.77-7.54, p <0.001). There was a trend towards lower job satisfaction ( p =0.012), less satisfaction with career goals ( p =0.035) and worse work-life balance ( p =0.0021) in female surgeons., Discussion and Conclusion: This survey underlines that a significant proportion of neurosurgeons - in particular females - continue to experience gender inequity & discrimination at work, which may translate into lower work-related satisfaction. A better understanding of the gender-related aspects of job satisfaction is an important step to improving gender equity in our profession., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Authors.)

Introduction: Outcome assessments after surgery for degenerative lumbar disorders (DLDs) rely on subjective patient-reported outcomes (PROMs). New objective functional capacity tests, like the smartphone-based 6-min walking test (6WT), have been introduced but presumably also do not reflect the patient's real-life functional performance., Research Question: Pilot study to analyze changes in smartphone-based real-life activity data for physical performance outcome in patients undergoing surgery for DLD., Material and Methods: Prospective observational study of DLD patients. Objective functional capacity and subjective outcomes were measured using 6WT and PROMs. Real-life physical performance data were acquired retrospectively using Apple iPhone Health data and compared against objective capacity and subjective outcomes., Results: Eight patients (mean 46 years, 62% male) provided 286.858 smartphone mile counts. PROMs and physical capacity (6WT) significantly improved postoperatively. 6WT results increased from 352m pre-to 555/567m at 6/12 weeks postoperatively (p ​= ​0.03). For physical performance a linear mixed effect models showed an increase in daily distance in the first 4 months after surgery (slope +0.178; p ​< ​0.001). However, those increases reversed from 4 until 12 months postoperatively (negative slope estimate of -0.076; p ​< ​0.001). Smartphone-derived physical performance measures showed a positive correlation with corresponding physical capacity in the 6WT (R ​= ​0.57,p ​= ​0.004) and negative correlations with PROMs (COMI: R ​= ​-0.62p ​= ​0.001; ZCQ-Physical-Function: R ​= ​-0.68,p ​< ​0.001; ZCQ-Symptom-Severity: R ​= ​-0.52,p ​= ​0.009)., Discussion and Conclusion: Smartphone-based real-life activity data allows for longitudinal physical performance assessment. Physical performance correlated with physical capacity and patient's subjective perception of disability. However, physical performance may be more resistant to postoperative longtime change which should consult a more cautious use as objective outcome measure., (© 2022 The Authors.)

Introduction: The postoperative functional status of patients with intracranial tumors is influenced by patient-specific factors, including age., Research Question: This study aimed to elucidate the association between age and postoperative morbidity or mortality following the resection of brain tumors., Material and Methods: A multicenter database was retrospectively reviewed. Functional status was assessed before and 3-6 months after tumor resection by the Karnofsky Performance Scale (KPS). Uni- and multivariable linear regression were used to estimate the association of age with postoperative change in KPS. Logistic regression models for a ≥10-point decline in KPS or mortality were built for patients ≥75 years., Results: The total sample of 4864 patients had a mean age of 56.4 ​± ​14.4 years. The mean change in pre-to postoperative KPS was -1.43. For each 1-year increase in patient age, the adjusted change in postoperative KPS was -0.11 (95% CI -0.14 - - 0.07). In multivariable analysis, patients ≥75 years had an odds ratio of 1.51 to experience postoperative functional decline (95%CI 1.21-1.88) and an odds ratio of 2.04 to die (95%CI 1.33-3.13), compared to younger patients., Discussion: Patients with intracranial tumors treated surgically showed a minor decline in their postoperative functional status. Age was associated with this decline in function, but only to a small extent., Conclusion: Patients ≥75 years were more likely to experience a clinically meaningful decline in function and about two times as likely to die within the first 6 months after surgery, compared to younger patients., (© 2021 The Authors.)