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The National Health Service faces substantial challenges with staffing in the face of administrative turbulence just after a global pandemic resulting in significant economic losses. This staffing crisis extends to neurosurgical training with pervasive problems with the balance between trainees and consultants. In the face of Brexit, after the impact of the European Working Time Directive, these challenges provide an opportunity to explore possible solutions to improving training and staff retention. The recommended solutions include ensuring appropriate workforce planning and using novel (and already available) resources to revamp the structure of neurosurgery training and improving the attainment of surgical competence and staff retention. Creating a sustainable neurosurgery training program to adequately fill gaps in the National Health Service will require long-term solutions and the commitment of multiple stakeholders. The first step to achieving these goals would be to maximize the available opportunities to allow trainees maximize training time to become competent day-one consultants.

Background: The global burden of traumatic brain injuries continues to remain grossly underestimated and is thought to cost about US$400 billion annually. Elderly individuals have the highest age-specific rates of TBIs and are more likely to take anticoagulant medication than other age groups and are therefore theoretically at a higher risk of morbidity and mortality following head injuries. However, the evidence for these worse outcomes is at best unclear, and this has a significant impact on decision-making in clinical settings, sometimes resulting in unnecessary delays to treatment.Methods: This protocol has been developed using the PRISMA-P guidelines. We will search the main clinical indexing databases (including PubMed/MEDLINE, EMBASE, Cochrane reviews, and ClinicalTrials.gov) for studies that evaluated outcomes in terms of morbidity and mortality among anticoagulated individuals aged over 65, to identify all English language studies published between the years 2000 and 2021. The identified studies will then be screened using pre-determined eligibility criteria detailed in the body of this work. Finally, two independent reviewers will screen, select, evaluate the included studies for quality, and extract data related to the use of anticoagulants in the elderly from all relevant sources. A logically sound analytic framework will then be employed to determine the impact of the use of anticoagulation on outcomes as outlined. Discussion: This study aims to identify the existing evidence for outcomes in this population, contribute to the current body of knowledge, and provide more explicit guidance for clinical practice. We envisage that the findings surrounding outcomes in the head-injured, anticoagulated elderly population will guide clinicians towards better decision-making in both the in-patient and out-patient setting and contribute to the development of clinical guidelines. Systematic review registration: This systematic review is registered on the PROSPERO database with registration number: CRD42021220974

AIMS Awake craniotomy for brain tumour resection aims to increase the extent of resection while minimising neurological deficit. The major concerns for patients during awake craniotomies include peri-operative discomfort/pain and anxiety for some patients. Older patients are generally not offered aggressive operative options due to longer lengths of hospital stay (LOS), expected higher rates of peri-operative morbidity/mortality, and poorer survival. However, increased extent of glioma resection is associated with greater overall and progression-free survival. Furthermore, previous studies have shown that awake craniotomies are well tolerated in elderly patients. This study aims to evaluate our experience in awake craniotomies for glioma resection in patients over 65 years old. METHOD Seventeen elderly patients who had undergone awake craniotomies at University Hospitals of North Midlands between 2015 and 2021 were included. Outcome measures included LOS, post-operative morbidity/mortality, and the difference between pre- and post-operative Hospital Anxiety and Depression scores (HADS). RESULTS There was an 11% operative mortality rate in our cohort. The average LOS was 5.7 days. The median pre- and post-operative score at 6 months was 1 indicating that there is no difference post-operatively. There was a positive net difference between pre- and post-operative anxiety/depression scores in our cohort. CONCLUSION Awake craniotomies are generally well tolerated among the elderly patients with unchanged post-operative performance status and improved HADS scores. These findings suggest that awake craniotomies should be offered to elderly patients if deemed appropriate.