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Introduction: Professional society awards can substantially impact career trajectory of awardees in neurosurgery. Past studies have discussed the demographics of neurosurgery conference awardees in terms of gender and professional experience; however, a full assessment of awardee qualities and characteristics has yet to be studied., Objective: The goal of this study is to provide a comprehensive evaluation of neurosurgical society winners that focuses on gender, race, academic degrees, and institutional/geographic affiliation., Methods: Data of awardees across 14 neurosurgical societies from 2019 to 2022 was recorded. Variables recorded include professional society, award classification, year won, age, gender, race and ethnicity, board certification status, MD graduation year, degrees obtained, awardee home institution location, h-index, and NIH-funding. Statistical analysis was performed using IBM SPSS., Results: A total of 102 unique awards from 14 different societies between 2019 and 2022 were identified. Significantly more men (83 %) as compared to women (17 %) were awardees (p < 0.001). Awardees were significantly more likely to be Caucasian as compared to any other race (p < 0.001), and Caucasian awardees were more likely to be board certified and receive NIH funding. A higher proportion of male awardees had a PhD; however, the majority of all awardees were significantly more likely to not have a PhD or be board certified (p < 0.001). The majority of awardees were based in the Northeastern United States., Conclusions: Among winners of neurosurgical society awards, significant differences exist with respect to gender, race, ethnicity, degree type, and geographic location. Future research endeavors are needed to explore the reason for why these differences exist to ultimately develop strategies that promote equal opportunities for all neurosurgeons., Competing Interests: Declaration of competing interest 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., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: This study aimed to examine factors that may affect UK neurosurgeons' ability to publish single-author papers. These include demographic factors (e.g. gender, skin colour), biographical factors (e.g. whether they obtained a PhD or the ranking of the university from which they graduated or with which they are currently affiliated), and name characteristics., Methods: Names of all neurosurgeons working in the UK in May 2023 were obtained from the Specialist Info website. Scopus was used to obtain bibliometrics. Publicly available online sources were used to obtain biographical and demographic information., Results: Approximately 1 out of 3 neurosurgeons had published at least one single-author paper. Of the 398 single-author papers published by the whole group of 384 neurosurgeons, 69 were open access, 44 were reviews, 64 were editorials, 71 were articles, and 219 were classified as 'other'. Their first single-author paper was published on average 15.2 years after medical school graduation and on average 9 years after their first publication (any author position). In 13 neurosurgeons their first-single author paper was a review, in 14 it was an editorial, in 24 an article, and in 57 it was classified as 'other'. The impact factor of the journal in which they published their first single-author paper was on average 11.1 (Median = 2.4). Single-author papers do not differ in number depending on gender or skin colour. However, there were more single-author publications among full professors, neurosurgeons who graduated from a top university for their medical degree, those who had a PhD, and those who are currently affiliated with a university. More senior neurosurgeons had more single-author publications. Neurosurgeons with more popular forenames, whose full name's perceived ethnicity was UK/Irish or had longer consonant sequences in their surname had more single-author papers., Conclusion: This is the first study to thoroughly examine single-author publications in a group of medical professionals and examine whether they are associated with certain socio-demographic and name characteristics., Competing Interests: Declaration of competing interest The author declares that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

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: This study examines the lasting impact of historical redlining on contemporary neurosurgical care access, highlighting the need for equitable healthcare in historically marginalized communities., Objective: To investigate how redlining affects neurosurgeon distribution and reimbursement in U.S. neighborhoods, analyzing implications for healthcare access., Methods: An observational study was conducted using data from the Center for Medicare and Medicaid Services (CMS) National File, Home Owner's Loan Corporation (HOLC) neighborhood grades, and demographic data to evaluate neurosurgical representation across 91 U.S. cities, categorized by HOLC Grades (A, B, C, D) and gentrification status., Results: Of the 257 neighborhoods, Grade A, B, C, and D neighborhoods comprised 5.40%, 18.80%, 45.8%, and 30.0% of the sample, respectively. Grade A, B, and C neighborhoods had more White and Asian residents and less Black residents compared to Grade D neighborhoods ( p  < 0.001). HOLC Grade A (OR = 4.37, 95%CI: 2.08, 9.16, p  < 0.001), B (OR = 1.99, 95%CI: 1.18, 3.38, p  = 0.011), and C (OR = 2.37, 95%CI: 1.57, 3.59, p  < 0.001) neighborhoods were associated with a higher representation of neurosurgeons compared to Grade D neighborhoods. Reimbursement disparities were also apparent: neurosurgeons practicing in HOLC Grade D neighborhoods received significantly lower reimbursements than those in Grade A neighborhoods ($109,163.77 vs. $142,999.88, p  < 0.001), Grade B neighborhoods ($109,163.77 vs. $131,459.02, p  < 0.001), and Grade C neighborhoods ($109,163.77 vs. $129,070.733, p  < 0.001)., Conclusion: Historical redlining continues to shape access to highly specialized healthcare such as neurosurgery. Efforts to address these disparities must consider historical context and strive to achieve more equitable access to specialized care., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Kabangu, Dugan, Joseph, Hernandez, Newsome-Cuby, Fowler, Bah, Fry and Eden.)

Although at least half of medical students are women, neurosurgery is not often preferred by women, and the proportion of female neurosurgeons who can participate in the academic platform is very low. In this study, we aimed to show the role of female neurosurgeons in the Turkish Neurosurgical Society and to describe the number and the location of female neurosurgeons in Turkey. We examined the age, academic rank, years of work in the profession, membership rate in society subgroups, h-index parameters, and relationships of certificated female neurosurgeons registered in the Turkish Neurosurgical Society. We examined gender rate differences between society subgroups using chi-square tests. A P value < 0.05 was considered statistically significant. According to the year-end 2020 data of the Turkish Neurosurgery Society, 94 (5.5%) of the 1699 neurosurgery specialists registered in Turkey are women. There are currently 94 board-certified female neurosurgeons between the ages of 31 and 92 years; 10 are full professors (10.6%), 16 are associate professors (17%), 5 are assistant professors (5.3%), and 63 are neurosurgery specialist physicians (67%). Female neurosurgeons are present among six of the subfields categorized by the Turkish Neurosurgical Society: 7 in pediatric neurosurgery (11.47%); 8 in spinal and peripheral nerve surgery (2.4%); 3 in neurovascular surgery (2.02%); 7 in functional neurosurgery (5.8%); 11 in neuroanatomy (9.2%); and 23 in neurooncology (6.9%). The number of female neurosurgeons in Turkey continues to grow each year. To increase the proportion of women in this field, it is important to support female neurosurgeons and enable them to take on more tasks., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: The initial COVID-19 pandemic shutdown led to the canceling of elective surgeries throughout most of the USA and Canada., Objective: This survey was carried out on behalf of the Parkinson Study Group (PSG) to understand the impact of the shutdown on deep brain stimulation (DBS) practices in North America., Methods: A survey was distributed through RedCap® to the members of the PSG Functional Neurosurgical Working Group. Only one member from each site was asked to respond to the survey. Responses were collected from May 15 to June 6, 2020., Results: Twenty-three sites participated; 19 (83%) sites were from the USA and 4 (17%) from Canada. Twenty-one sites were academic medical centers. COVID-19 associated DBS restrictions were in place from 4 to 16 weeks. One-third of sites halted preoperative evaluations, while two-thirds of the sites offered limited preoperative evaluations. Institutional policy was the main contributor for the reported practice changes, with 87% of the sites additionally reporting patient-driven surgical delays secondary to pandemic concerns. Pre-post DBS associated management changes affected preoperative assessments 96%; electrode placement 87%; new implantable pulse generator (IPG) placement 83%; IPG replacement 65%; immediate postoperative DBS programming 74%; and routine DBS programming 91%., Conclusion: The COVID-19 pandemic related shutdown resulted in DBS practice changes in almost all North American sites who responded to this large survey. Information learned could inform development of future contingency plans to reduce patient delays in care under similar circumstances., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Previous research in neurosurgery has examined academic productivity for U.S. medical graduates and residents. However, associations between scholarly output and international medical education, residency training, and fellowship training are scarcely documented., Methods: We identified 1671 U.S. academic neurosurgeons in 2020 using publicly available data along with their countries of medical school, residency, and fellowship training. Using Scopus, h-index, number of publications, and number of times publications were cited were compiled. Demographic, subspeciality, and academic productivity variables were compared between training locations using univariate analysis and multivariable linear regression., Results: Of the current neurosurgery faculty workforce, 16% completed at least 1 component of their training abroad. Canada was the most represented international country in the cohort. Academic productivity for neurosurgeons with international medical school and/or international residency did not significantly differ from that of neurosurgeons trained in the United States. Neurosurgeons with ≥1 U.S. fellowships or ≥1 international fellowships did not have higher academic productivity than neurosurgeons without a fellowship. However, dual fellowship training in both domestic and international programs was associated with higher mean h-index (β = 6.00, 95% confidence interval 1.01 to 10.98, P = 0.02), higher citations (β = 2092.0, 95% confidence interval 460.1 to 3724.0, P = 0.01), and a trend toward higher publications (β = 36.82, 95% confidence interval -0.21 to 73.85, P = 0.051)., Conclusions: Neurosurgeon scholarly output was not significantly affected by international training in medical school or residency. Dual fellowship training in both a domestic and an international program was associated with higher academic productivity., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: Large disparities in access to neurosurgical care are known, but there are limited data on whether geographic distribution of the neurosurgery workforce potentially plays a role in these disparities. The goal of this study was to identify the geographic distribution of neurosurgeons in the United States and to study the association of the per capita workforce distribution with socioeconomic characteristics of the population., Methods: The number of practicing neurosurgeons in the United States in 2016 was obtained from the 2017-2018 American Medical Association Masterfile contained within the Area Health Resource File. The association of the number of neurosurgeons per 100,000 population with socioeconomic characteristics was assessed through linear regression analysis at Hospital Referral Region (HRR) level., Results: The median number of neurosurgeons per capita across all HRRs was 1.47 neurosurgeons per 100,000 population (interquartile range, 1.02-2.27). Bivariable analysis showed that greater supply of neurosurgeons was positively associated with regional levels of college education, median income, and median age. The number of neurosurgeons per capita at the HRR level was negatively associated with unemployment, poverty, and percent uninsured., Conclusions: Regions characterized by low socioeconomic status have fewer neurosurgeons per capita in the United States. Low income, low number of college graduates, and high unemployment rate are associated with fewer numbers of neurosurgeons per capita. Further research is needed to determine if these geographic workforce disparities contribute to poor access to quality neurosurgical care., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: History has taught us that Mexican culture has been largely supported by women, despite gender prejudice from the society. Neurosurgery has not been the exception. Therefore, we investigated the challenges and influence of female neurosurgeons in Mexico., Methods: We conducted a review of the literature and an analysis of the internal database of the Mexican Society of Neurological Surgery focusing on 3 topics: 1) the historical presence of women and gender inequality in Mexico; 2) the life and legacy of the woman who became the first neurosurgeon in Mexico and in Latin America; and 3) the participation of women in neurosurgery in the past 3 decades., Results: In Latin America, the first woman in neurosurgery was María Cristina García-Sancho, who completed her neurosurgical training in 1951. Currently, women represent 6.2% of the total members of the Mexican Society of Neurological Surgery (MSNS). This percentage is still low, although data collected in this study suggest that it might increase in the next few years because 16.7% of Board Directors of the MSNS are women, the next elected president is a female neurosurgeon, and 14.5% of neurosurgery residents are women., Conclusions: Although a steady increase has occurred of women in neurosurgery in Mexico, there is still work to do, especially to overcome the barriers related to the old assumptions of the cultural and social roles of women., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Work-related musculoskeletal disorders (WMSDs) affect a significant percentage of the neurosurgical workforce. The aim of the current questionnaire-based study was to examine the prevalence of WMSDs amongst neurosurgeons, identify risk factors, and study the views of neurosurgeons regarding ergonomics., Methods: From June to August 2020, members of the "European Association of Neurosurgical Societies," the "Neurosurgery Research Listserv," and the "Latin American Federation of Neurosurgical Societies" were asked to complete an electronic questionnaire on the topics of WMSDs and ergonomics., Results: A total of 409 neurosurgeons responded to the survey, with a 4.7 male to female ratio. Most of the surgeons worked in Europe (76.9%) in academic public hospitals. The vast majority of the participants (87.9%) had experienced WMSDs, mainly affecting the shoulder, neck, and back muscles. The most common operations performed by the participants were "Craniotomy for convexity/intrinsic tumors" (24.1%) and "Open lumbar basic spine" (24.1%). Neurosurgeons agreed that ergonomics is an underexposed area in the neurosurgical field (84.8%) and that more resources should be spend (87.3%) and training curricula changes should be made (78.3%) in order to alleviate the burden of WMSDs on neurosurgeons. Univariate analysis did not reveal any associations between the development of WMSDs and age, gender, tenure, average duration of operation, operating time per week, type of operation, and surgical approach., Conclusions: The problem of WMSDs ought to be more closely addressed and managed by the neurosurgical community. More studies ought to be designed to investigate specific ergonomic parameters in order to formulate practice recommendations.

Objective: The Patient Protection and Affordable Care Act (ACA) sought to expand access to health care for 46 million uninsured Americans. Increasing consumer coverage and ensuring affordability of care have raised concerns about ACA Marketplace plans with limited in-network physician coverage (narrow network plans). We assessed the neurosurgery coverage of ACA Marketplace plans in Arizona., Methods: The Health Insurance Marketplace website was used to identify ACA Marketplace plans in Arizona. Plan-specific details were examined to search for in-network neurosurgeons (2016-2019). Physician- and patient-level information was obtained using Intellimed health care databases, which provide specific neurosurgery diagnosis-related group information., Results: Although 5 insurance providers offered plans on the ACA Marketplace in Arizona, only 1 plan was available in 13 of 15 counties (87%). Evaluation of in-network coverage found that all in-network outpatient neurosurgery providers are in 5 of 15 counties (33%). Most of the other counties (9 of 10) have neurosurgery facilities, but do not have in-network access to neurosurgical care within the county (∼1.1 million people or 15% of the state population)., Conclusions: By narrowing the network of providers, insurance companies are attempting to maintain fiscal viability of their ACA Marketplace products. However, 10 of the 15 counties (67%) in Arizona do not have access to outpatient neurosurgical care through these plans despite the presence of neurosurgical facilities in most counties. Access to neurosurgical care requires consideration of network coverage in policies designed to expand coverage and coverage options for patients insured through the ACA Marketplace., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: In Europe, aneurysm treatment performed by dually trained neurosurgeons is extremely scarce. We provide outcome data for un-ruptured aneurysm patients treated at a European hybrid center to prove that hybrid neurosurgeons achieve clinical and angiographical results allowing to integrate hybrid neurosurgery into routine aneurysm treatment. This will not only help to maintain neurovascular microsurgical skills but will influence staff costs in related hospitals., Methods: We retrospectively analyzed all consecutively treated un-ruptured aneurysm patients between 2000 and 2016. The decision-making took into account the pros and cons of both modalities and considered patient and aneurysm characteristics. Clinical outcome was assessed by the modified Rankin scale (mRS). Occlusion rates were stratified into grade I for 100%, grade II for 99-90%, and grade III for <90% occlusion. To account for the introduction of stents, two treatment periods (p1, 2000 to 2008; p2, 2009 to 2016) were defined., Results: The study population consisted of 274 patients (median age 55 years) harboring 338 un-ruptured aneurysms. Microsurgery (MS) was performed in 51.8% and endovascular therapy (EVT) in 43.1%; 5.1% required combined treatment. Overall, 93% showed a favorable clinical outcome (mRS 0-2), 94.3% after MS and 91.5% after EVT. Grade I aneurysm occlusion was achieved in 82.6% patients, 91.9% after MS and 72.9% after EVT. Procedure-related complications occurred after MS in 5.6% and after EVT in 4.4% patients. Mortality was recorded for five (1.8%) patients, one patient after MS and four after EVT. For the EVT cohort, significant improvement from p1 to p2 was seen with clinical outcomes (P=0.030, RR = 0.905, CI: 0.8351-0.9802) and occlusion rates (P=0.039, RR = 0.6790, CI: 0.499-0.923)., Conclusion: Hybrid neurosurgeons achieve qualified clinical and angiographic results. Dual training will allow to maintain neurovascular caseloads and preserve future aneurysm treatment within neurosurgery. Furthermore economic benefits could be observed in hospital management.

The usefulness of 3-dimensional (3D)-printed disease models has been recognized in various medical fields. This study aims to introduce a production platform for patient-specific 3D-printed brain tumor model in clinical practice and evaluate its effectiveness. A full-cycle platform was created for the clinical application of a 3D-printed brain tumor model (3D-printed model) production system. Essential elements included automated segmentation software, cloud-based interactive communication tools, customized brain models with exquisite expression of brain anatomy in transparent material, adjunctive devices for surgical simulation, and swift process cycles to meet practical needs. A simulated clinical usefulness validation was conducted in which neurosurgeons assessed the usefulness of the 3D-printed models in 10 cases. We successfully produced clinically applicable patient-specific models within 4 days using the established platform. The simulated clinical usefulness validation results revealed the significant superiority of the 3D-printed models in surgical planning regarding surgical posture (p = 0.0147) and craniotomy design (p = 0.0072) compared to conventional magnetic resonance images. The benefit was more noticeable for neurosurgeons with less experience. We established a 3D-printed brain tumor model production system that is ready to use in daily clinical practice for neurosurgery.

Neurosurgery is male dominated with women representing only 12% of residents and 5% of practicing neurosurgeons. The conflicting demands of training versus pregnancy and motherhood are significant deterrents to women entering the field. We examined pregnancy incidence and timing, perinatal complications, and the perceived career impact of motherhood on female neurosurgeons using an anonymous survey of 643 training, practicing, and retired female neurosurgeons from the United States. Among 260 respondents, 50.8% (132/260) reported pregnancies, with an average age at first pregnancy that was significantly higher than the national average (32.1 vs 26.3 yr). In all, 40.1% (53/132) of respondents reported perinatal complications in at least one of their pregnancies. Only 25% (33/132) of respondents noted designated program maternity allowances. The most significant challenges associated with being a mother and neurosurgeon reported were issues relating to work/life balance, "mommy guilt," and sleep deprivation. A majority of respondents, 70.1% (82/116), reported fear of backlash from co-residents, partners, and staff, as well as hindered career advancement related to childbearing. Female neurosurgeons face challenges surrounding family planning different from those faced by male practitioners. Higher perinatal and fetal complications, backlash from colleagues, and demanding workload are significant issues. Progress requires institutional support and mentorship for women to create a more diverse field of practitioners., (© Congress of Neurological Surgeons 2021.)

Background: Trauma mortality disproportionately affects populations farther from potentially lifesaving trauma care, and traumatic brain injury (TBI) is no exception. Previous examinations have examined proximity to trauma centers as an explanation for trauma mortality, but little is known about the relationship between proximity to neurosurgeons specifically in TBI mortality., Materials and Methods: In this cross-sectional study, county-level TBI mortality rates from 2008 to 2014 were examined in relation to the distance to the nearest neurosurgeon and trauma facility. The locations of practicing neurosurgeons and trauma facilities in the United States were determined by geocoding data from the 2017 Medicare Physician and Other Supplier and Provider of Services files (respectively). The association between TBI mortality and the distance from the population-weighted centroid of the county to a closest neurosurgeon and trauma facility was examined using multivariate negative binomial regression., Results: A total of 761 of the 3108 counties (24.5%) in the continental United States were excluded from the analysis because they had 20 or fewer TBI deaths during this time, producing unstable estimates. Excluded counties accounted for 1.67% of the US population. Multivariate analysis revealed a county's mortality increased 10% for every 25 miles from the nearest neurosurgeon (adjusted incident rate ratio: 1.10 [95% confidence interval: 1.08-1.12]; P < 0.001). The distance to the nearest trauma facility was not found to be significantly associated with mortality (adjusted incident rate ratio: 1.01 [95% confidence interval: 0.99-1.03]; P = 0.36)., Conclusions: These findings suggest that proximity to neurosurgeons may influence county-level TBI mortality. Further research into this topic with more granular data may help to allocate scarce public health resources., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: To provide the status of women neurosurgeons (WNS) in academic faculty and/or leadership positions in neurosurgery in the United States., Methods: Neurosurgery academic programs were defined as having an Accreditation Council for Graduate Medical Education (ACGME) neurosurgery residency program (NSRP). Using a Google search, gender, academic rank, postgraduate degrees, academic and clinical titles, and subspecialty were recorded for each neurosurgery faculty. Officer gender was recorded for the top 7 neurosurgery U.S. organizations, 7 subspecialty sections, and 50 state neurosurgical societies., Results: WNS were faculty at 77% (89/115) of ACGME NSRPs and constituted 10% of the workforce (186/1773). WNS residents were in 92% of ACGME NSRPs and constituted 19% of the workforce (293/1515). Two NSRPs (8%) had neither WNS faculty nor WNS residents. Of NSRPs without WNS faculty, 52% (13/25) had a faculty size >10. WNS accounted for 3% of NSRP chair positions. Academic rank of WNS faculty was lower than academic rank of men neurosurgeons faculty (P < 0.05). WNS faculty had a higher number of postgraduate degrees (P < 0.05). Pediatrics was the most common subspecialty (30%) among WNS. Over time, WNS held 1% of the leadership positions within the top 7 U.S. neurosurgery organizations and 7% within the 7 subspecialty sections. Over the past 20 years, 28% (14/50) of U.S. state neurosurgical societies had WNS serve as president., Conclusions: In 2020, the gender gap for U.S. WNS faculty and residents still exists. By providing informed benchmarks, our study might help neurosurgery organizations, medical school leadership, hiring committees, editors, and conference speakers to plan their next steps., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Social media has become an important communication tool in modern life, and its use is undoubtedly increasing worldwide. Given the rising importance of social media in the health care system, little is known about neurosurgeons' social media use and interactions in the context of professional purposes. This study aimed to analyze social media usage and opinions among neurosurgeons in terms of age, gender, and practice setting., Methods: An online survey was administered to neurosurgeons worldwide. A total of 1119 neurosurgeons from 104 different countries responded to the questionnaire., Results: All respondents were members of at least 1 social media platform. Older neurosurgeons and neurosurgeons in nonacademic settings spent less time on social media (P < 0.05). Communication with peers via social media decreased with age, while communication via e-mail increased (P < 0.05). Most respondents perceived the effect of social media to be beneficial to neurosurgery (very beneficial [28.73%], somewhat beneficial [35.55%]). More women than men considered that social media platforms provided a greater chance for networking opportunities, learning about a new study or conference, and providing rapid and widespread knowledge transfer (P < 0.05). False guidance (44.68%) and violation of privacy (41.64%) were thought to be the main disadvantages., Conclusions: Social media use, opinions, and attitudes among neurosurgeons vary depending on their age, gender, and practice setting. Most neurosurgeons stated that the use of social media could have beneficial and advantageous effects on neurosurgery practice, while the frequency of misleading information and lack of privacy were perceived as barriers., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Publication metrics such as the author-level h-index are often used to evaluate and compare research productivity in academia. The h-index, however, is not a field-normalized statistic and has been criticized as inappropriate for comparison of authors from different fields. For example, fields such as internal medicine have a larger audience and thus afford publications a higher likelihood of increased citations compared with a perhaps equally impactful paper in a smaller field such as neurosurgery. The National Institutes of Health (NIH) has developed a new field-normalized article-level metric called the relative citation ratio (RCR) that can be used to more accurately compare author productivity between fields. Spine represents a distinct subset of neurosurgery with a designated fellowship and distinct differences in the RCR metrics. The authors look to analyze the unique results found in the academic spine neurosurgeon RCR values compared with all academic neurosurgeons., Purpose: The assessment of academic physicians should use field-independent publication metrics to measure the improvement of grant outcomes, promotion, and continued evaluation of research productivity. Here, we provide an analysis of RCR indices for 358 academic spine neurosurgeons in the United States, including the mean RCR of each author's total publications and the weighted RCR, which is the sum of all publication-level RCR values of an author. We further assess the impact of gender, career duration, academic rank, and Ph.D. acquisition on the RCR scores of U.S. academic spine neurosurgeons., Methods: The mean RCR is the total citations per year of a publication divided by average citations per year received by NIH-funded papers in the same field. A value of 1 is the normal NIH-funded standard. iCite database searches were performed for all physician faculty members affiliated with accredited neurological surgery programs who have subspecialized in spine as of November 1, 2019. Gender, career duration, academic rank, additional degrees, total publications, mean RCR, and weighted RCR were collected for each individual. RCR and weighted RCR were compared between variables to assess patterns of analysis., Results: A total of 358 fellowship-trained academic spine neurosurgeons from 125 institutions were included in the analysis. Exceptional research productivity was noted, with a median RCR of 1.38 (interquartile range = 0.94-1.95) and a weighted median RCR of 25.28 (interquartile range = 6.87-79.93). Overall, gender and academic rank were associated with increased mean RCR and weighted RCR values. Career duration and Ph.D. acquisition were not. All subgroups analyzed had an RCR value above 1.0, with professor-level faculty or department chair having the highest mean and weighted RCR values overall., Conclusions: Current academic spine neurosurgeons have high median RCR values relative to the NIH standard RCR value of 1.0. Relative to the field of neurological surgery overall, RCR values for the spine subspecialty are comparable. These data offer a more accurate means for self-evaluation of academic neurosurgeons as well as evaluation of faculty by institutional and departmental leaders., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Perioperative craniotomy practices depend mainly on neurosurgeon preferences. To investigate the variations in these preferences, we surveyed neurosurgeons in Poland regarding different aspects of their practices., Methods: Anonymous questionnaires were circulated in 2019 at the neurosurgery conferences in Poland. We then analyzed the responses, categorized in subgroups by sex, affiliation, and stage of training., Results: A total of 114 responses to the questionnaire were obtained. For surgical site exposure, regional hair shaving was the most common pattern (64.9%), followed by whole-scalp (19.3%) and strip line shaving (12.3%). Most respondents (65.8%) used clamp-based devices for bone flap fixation, and approximately one third (30.7%) reported using bone suturing. During cranioplasty, respondents most often used artificial bone implants (69.3%), followed by a preserved bone flap from the patient (24.5%). More than three quarters reported that they (77.2%) performed routine radiologic evaluation after uncomplicated brain tumor surgery. Most patients (64.0%) were discharged between the third and sixth postoperative days. Almost half of emergent surgeries (48.2%) and most elective surgeries (89.5%) were performed with the help of an assistant surgeon. No significant differences were found in practice between the sexes or by affiliation or training stage. We inferred an influence of regional economic status on some of the reported choices., Conclusions: Perioperative craniotomy practices among Polish neurosurgeons show a significant heterogeneity. Economic factors can explain some choices, but others trace to a conservative mindset. Further studies are needed to identify which factors are most relevant and to identify approaches to a standardized method of care., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: To understand how physicians in the United States manage patients with small unruptured intracranial aneurysms and factors that influence the management., Methods: An online survey questionnaire was designed through SurveyMonkey and distributed electronically to The Society of Interventional Surgery, American Association of Neurological Surgeons/Congress of Neurological Surgeons Joint Section of Cerebrovascular Surgery, American Academy of Neurology, and Massachusetts Neurologic Association. All participations were voluntary and anonymous., Results: Among all the participants, 53.8% of them were neurosurgeons, 33.0% were neurointerventional radiologists, and 13.2% were neurologists. For management of aneurysms 2-4 mm, 87.8% of respondents favored routine surveillance with imaging follow-up, 3.8% preferred routine treatment, and 8.5% recommended routine treatment or follow-up only for high risk patients. In total, 25.5% preferred annual follow-up, and 67.9% liked follow-up once in a year and then space out at various intervals. For aneurysms between 5 and 7 mm, 73.6% supported routine treatment, 20.8% favored surveillance with imaging follow-up, and 5.7% recommended treating or follow-up only high-risk groups. In total, 58.5% preferred annual follow-up, whereas 34.9% liked follow-up once in a year and then space out at various intervals. For routine follow-up, 64.1% of the physicians chose magnetic resonance angiography without contrast, and 40.6% preferred computed tomography angiography., Conclusions: For aneurysms 2-4 mm, majority of the physicians preferred regular follow-up, whereas for aneurysms 5-7 mm, the majority favor treatment. There remains heterogeneity in practice among physicians in the United States regarding follow-up strategies for small unruptured aneurysms. Further studies are needed to evaluate the optimal management strategy, follow-up frequency and duration of imaging for small unruptured intracranial aneurysms., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: The treatment of patients with ≥11 brain metastases (BMs) with stereotactic radiosurgery (SRS) alone has yet to be established. The aim of this study was to compare results of SRS alone in patients with 5-10 BMs versus 11-20 BMs., Methods: This was an institutional review board-approved, retrospective cohort study using our prospectively accumulated database including 1515 patients with 5-10 tumors and 804 patients with 11-20 tumors treated with Gamma Knife SRS by 2 experienced neurosurgeons between 1998 and 2018. The Kaplan-Meier method was applied to determine post-SRS survival times, and competing risk analyses were used to estimate cumulative incidences of the secondary end points., Results: The post-SRS median survival time was slightly longer in the group with 5-10 tumors (7.7 months) than in the group with 11-20 tumors (6.5 months) (P < 0.0001). Median survival time differences were statistically significant for patients with lung cancers but not for patients with breast, gastrointestinal tract, kidney, and other cancers. Multivariable analysis revealed female sex, better Karnofsky performance scale score, controlled primary cancer, and absence of extracerebral metastases to be statistically significant predictors of longer survival in the 2 patient cohorts. Crude and cumulative incidences of local recurrences were significantly lower in the group with 11-20 tumors than in the group with 5-10 tumors, while those of other secondary end points were similar to or lower in the group with 11-20 tumors than in the group with 5-10 tumors. Post-SRS outcomes were relatively poor in patients with 11-20 tumors from kidney or other cancers., Conclusions: Carefully selected patients with 11-20 BMs are not unfavorable candidates for SRS alone., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: We sought to determine the proportion and number of female neurosurgeons in the workforce at different stages of practice., Methods: The Physician Compare National Downloadable File data set was obtained from the Centers for Medicare & Medicaid Services for physicians who indicated "neurosurgery" as their primary specialty. Physician duplicates, physicians with no listed medical school graduation year, and physicians expected to be in residency (graduation years 2013-2019) were removed, yielding 4956 neurosurgeons. Five-year intervals were used to measure the number of male and female neurosurgeons by different stages of their careers. For example, graduates from years 2008-2012 were expected to be in their first 1-5 years of practice., Results: There were 405 female (8.2%) and 4551 male (91.8%) neurosurgeons. At 1-5 years of practice, 13.8% (105/760) were women; 6-10 years, 11.5% (94/820) women; 11-15 years, 8.9% (64/720) women; 16-20 years, 8.7% (59/682) women; 21-25 years, 7.4% (46/619) women; 26-30 years, 3.8% (20/520) women; 31-35 years, 3.6% (15/413) women; and 36 years or more, 0.5% women (2/422). The number of female neurosurgeons varied among states, ranging from 0 in Hawaii to 53 in California. The states with the lowest percentage of female neurosurgeons were Hawaii (0%), Oklahoma (3.1%), and Nevada (3.6%). The states with the highest percentage of female neurosurgeons were New Hampshire (20.0%), Vermont (16.7%), and Rhode Island (15.8%)., Conclusions: The number of practicing female neurosurgeons within the United States is increasing, as shown by the growing percentage of women who are earlier in their surgical careers., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: To perform an ecological study to analyze the geospatial distribution of neurosurgeons ≥60 years old and compare these data with the spread of 2019 novel coronavirus disease (COVID-19) across the United States., Methods: Data regarding distribution of COVID-19 cases were collected from the Environmental Systems Research Institute, and demographic statistics were collected from the American Association of Medical Colleges 2019 State Workforce Reports. These figures were analyzed using geospatial mapping software., Results: As of July 5, 2020, the 10 states with the highest number of COVID-19 cases showed older neurosurgical workforce proportions (the proportion of active surgeons ≥60 years old) of 20.6%-38.9%. Among states with the highest number of COVID-19 deaths, the older workforce proportions were 25.0%-43.4%. Connecticut demonstrated the highest with 43.4% of neurosurgeons ≥60 years old., Conclusions: Regional COVID-19 hotspots may coincide with areas where a substantial proportion of the neurosurgical workforce is ≥60 years old. Continuous evaluation and adjustment of local and national clinical practice guidelines are warranted throughout the pandemic era., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to characterize the payments made by medical industry to neurosurgeons from 2014 to 2018., Methods: A retrospective study was performed from January 1, 2014 to December 31, 2018 of the Open Payments Database. Collected data included the total number of industry payments, the aggregate value of industry payments, and the mean value of each industry payment made to neurosurgeons per year over the 5-year period., Results: A total of 105,150 unique surgeons, with 13,668 (12.99%) unique neurosurgeons, were identified to have received an industry payment during 2014-2018. Neurosurgeons were the second highest industry-paid surgical specialty, with a total 421,151 industry payments made to neurosurgeons, totaling $477,451,070. The mean average paid amount per surgeon was $34,932 (±$936,942). The largest proportion of payments were related to food and beverage (75.5%), followed by travel and lodging (14.9%), consulting fees (3.5%), nonconsulting service fees (2.1%), and royalties or licensing (1.9%), totaling 90.4% of all industry payments to neurologic surgeons. Summed across the 5-year period, the largest paid source types were royalties and licensing (64.0%; $305,517,489), consulting fees (11.8%; $56,445,950), nonconsulting service fees (7.3%; $34,629,109), current or prospective investments (6.8%, $32,307,959), and travel and lodging (4.8%, $22,982,165)., Conclusions: Our study shows that over the most recent 5-year period (2014-2018) of the Centers for Medicare and Medicaid Services Open Payments Database, there was a decreasing trend of the total number of payments, but an increasing trend of the total amount paid to neurosurgeons., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Recent technological advances have led to the development and implementation of machine learning (ML) in various disciplines, including neurosurgery. Our goal was to conduct a comprehensive survey of neurosurgeons to assess the acceptance of and attitudes toward ML in neurosurgical practice and to identify factors associated with its use., Methods: The online survey consisted of nine or ten mandatory questions and was distributed in February and March 2019 through the European Association of Neurosurgical Societies (EANS) and the Congress of Neurosurgeons (CNS)., Results: Out of 7280 neurosurgeons who received the survey, we received 362 responses, with a response rate of 5%, mainly in Europe and North America. In total, 103 neurosurgeons (28.5%) reported using ML in their clinical practice, and 31.1% in research. Adoption rates of ML were relatively evenly distributed, with 25.6% for North America, 30.9% for Europe, 33.3% for Latin America and the Middle East, 44.4% for Asia and Pacific and 100% for Africa with only two responses. No predictors of clinical ML use were identified, although academic settings and subspecialties neuro-oncology, functional, trauma and epilepsy predicted use of ML in research. The most common applications were for predicting outcomes and complications, as well as interpretation of imaging., Conclusions: This report provides a global overview of the neurosurgical applications of ML. A relevant proportion of the surveyed neurosurgeons reported clinical experience with ML algorithms. Future studies should aim to clarify the role and potential benefits of ML in neurosurgery and to reconcile these potential advantages with bioethical considerations.

Surgical experience is of paramount importance to reach therapeutic success and minimize operative complications. In the field of pituitary surgery, this led to the concept of Pituitary Center of Excellence (PTCOE) defined as a center where an interdisciplinary team works in collaboration and where surgeons can be trained appropriately to reach and keep excellence in daily practice. To review the literature to define the optimal referral population size to establish a PTCOE to optimize both training and specific field research. A review of the literature was performed about epidemiology. The time needed to observe 200 cases of PAs in a single PTCOE and to reach the minimal surgical experience threshold (MSET) was calculated for different referral population groups. The time needed to reach MSET decreased as population size increased. We defined a population as the optimal one to be served by a single PTCOE with a single dedicated neurosurgeon. PTCOEs should be established after an analysis of the referral population, number of cases suitable for surgical treatment and number of dedicated neurosurgeons.

Purpose: This comparative survey of surgical practice patterns between 2010 and 2020 aims to elicit trends in practice patterns for transsphenoidal surgery and to identify areas for improvement., Methods: Web-based surveys were sent to the International Society of Pituitary Surgeons via a membership listserv in 2010 and 2020. These 33-item surveys collected information on demographics, surgical approach, perceived advantages and disadvantages, and recommendations for improvements. Statistical analyses were conducted using the Mann-Whitney U test for continuous variables and Fisher's exact test for categorical variables., Results: There were 51 respondents in 2010 and 82 respondents in 2020. The majority were full-time academic surgeons from the United States or Europe. Preference for a purely endoscopic technique increased from 43% in 2010 to 87% in 2020. Preference for routinely working with an otolaryngologist or second neurosurgeon increased from 35 to 51%. Most surgeons (74%) reported that they were more likely to achieve a greater extent of resection with the endoscope, though 51% noted increased operating time. The most commonly rated advantage (34%) of endoscopic TSS was fewer postoperative nasoseptal perforations; the most commonly (34%) rated disadvantage was more postoperative complications, including cerebrospinal fluid leak. Respondents were divided on whether microscopic TSS should continue to be taught in residency. Many (32%) advocated for improved endoscopic instrumentation and team training., Conclusion: Endoscopic TSS is now the clearly preferred method for surgery amongst a cohort of higher-volume academic neurosurgeons. This trend is likely to continue, and this provides guidelines for future training.

Background: The aftermath of the Affordable Care Act (ACA) witnessed the rise of narrow networks, which feature fewer providers in exchange for lower premiums. Debate still continues on whether narrow networks provide adequate access to health care, especially in specialty care services such as neurosurgery. The objective of this article was to analyze the 2019 Marketplace plans' impact on delivering outpatient neurosurgical care in New Jersey., Methods: The 2019 Marketplace Public Use Files were queried for "silver" plans, identifying a total of 11 plans across 3 insurance companies. Online search engines were used to identify the number of in-network neurosurgeons within 20-25 miles of ZIP codes at the center of each county. The primary outcome was the number of neurosurgeon-deficient plans, defined as those having no in-network neurosurgeons within the assigned mile radius., Results: Of all individuals who purchased an insurance plan, 73% (185,797/255,246) opted for a silver plan. Out of 111 active neurosurgeons in New Jersey, 25% (28/111) did not participate in any of the silver plans. Analysis showed 8 plans as neurosurgeon-deficient in Sussex and Warren. Meanwhile, most of the silver plans provided access to >5 neurosurgeons within 20-25 miles of most (17/21) county centers., Conclusions: In more densely populated states such as New Jersey, the impact of narrow networks on neurosurgical coverage is less apparent. However, frustrations regarding access to care still exist because nearly 25% of neurosurgeons do not participate in the standard ACA insurance product. Furthermore, guidelines that define network adequacy in neurosurgery remain elusive, which calls for more robust parameters to monitor and ensure adequate access to health care., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Work-related musculoskeletal disorders (WMSDs) are a growing and probably undervalued concern for neurosurgeons and spine surgeons, as they can impact their quality of life and career length. This systematic review aims to ascertain this association and to search for preventive measures., Methods: We conducted a PRISMA-P-based review on ergonomics and WMSDs in neurosurgery over the last 15 years. Twelve original articles were included, of which 6 focused on spine surgery ergonomics, 5 cranio-facial surgery (mainly endoscopic), and one on both domains., Results: We found a huge methodological and content diversity among studies with 5 surveys, 3 cross-sectional studies, 2 retrospective cohorts, and 2 technical notes. Spine surgeons have sustained neck flexion and neglect their posture during surgery. In a survey, low back pain was found in 62% of surgeons, 31% of them with a diagnosed lumbar disc herniation, and 23% of surgery rate. Pain in the neck (59%), shoulder (49%), finger (31%), and wrist (25%) are more frequent than in the general population. Carpal tunnel syndrome showed a linear relationship with increasing cumulative hours of spine surgery practice. Among cranial procedures, endoscopy was also significantly related to shoulder pain while pineal region surgery received some attempts to optimize ergonomics., Conclusions: Ergonomics in neurosurgery remains underreported and lack attention from surgeons and authorities. Improvements shall target postural ergonomics, equipment design, weekly schedule adaptation, and exercise.

Purpose: In the general context of medical judicialization, spine surgeons are impacted by the part that medical responsibility and the risk of malpractice play in their actions and decisions. Our aim was to evaluate possible shifts in practices among private neurosurgeons who are highly exposed to this judicial risk and detect alterations in their pleasure in exercising their profession. We present the first national survey on French physicians' perception of surgical judicialization and consequences on their practice., Methods: An online survey was submitted to the 121 members of the French Society of Private Neurosurgery, who represent 29.1% of the total number of spine surgeons and perform 36.0% of the national total spine surgery activity. The French law (no-fault out-of-court scheme) significantly impacts these surgeons in the event of litigation., Results: A total of 78 surveys were completed (64.5% response rate): 89.7% of respondents experienced alteration of doctor-patient relationship related to judicialization and 60.2% had already refused to perform risky surgeries. Fear of being sued added negative pressure during surgery for 55.1% of respondents and 37.2% of them had already considered stopping their practice because of this litigation context., Conclusion: The increasing impact of medical liability is prompting practitioners to change their practice and perceptions. The doctor-patient relationship appears to be altered, negative pressure is placed on physicians and defensively, some neurosurgeons may refuse high-risk patients and procedures. This situation causes professional disenchantment and can ultimately prove disadvantageous for both doctors and patients., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Background: Contributions from Latin America to the global literature are scarce; until 2011, spine surgeons had published 320 articles in indexed journals., Methods: This systematic review evaluates the scientific production of the Mexican Association of Spine Surgeons (Asociación Mexicana de Cirujanos de Columna-AMCICO) from its inception in 1998 to 2018 with the PRISMA statement using PubMed and Google Scholar search engines. The inclusion criteria were spine-related articles in indexed journals providing any (or no) level of evidence with ≥1 AMCICO member as an author. Journal metrics, article metrics, and author variables were analyzed using SPSS version 25., Results: Of the 444 surgeons historically belonging to AMCICO, only 126 members contributed a total of 441 articles between 1998 and 2018. An average of 21.00 annual publications with an annual scientific output per capita of 0.05 was found. The most frequent evidence level was III (211 articles, 48%), the highest level was I (12 articles, 3%). The main study objective was clinical research, with 308 articles (70%), and the main study foci was trauma, with 103 articles (23%). An average impact factor of 0.16 and 0.92 was obtained for publications in Spanish and English, respectively., Conclusions: Scientific publications by AMCICO members are scarce, with a per capita annual index of 0.05 from a total of 441 articles in indexed journals. Second, the impact factor of these journals is low, with a mean value of 0.53. Further strategies should be implemented to increase the number and track the record of Mexican contributions to the scientific literature., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Enhanced Recovery After Surgery (ERAS) is the object of numerous publications in various surgical fields. Still, its value in spine surgery is not as recognized as it is in other surgical domains. Our aim was to report neurosurgeons' opinions about ERAS in spine surgery., Methods: From December 2019 to January 2020, members of the European Association of Neurosurgical Societies were asked to complete an online questionnaire regarding ERAS in spine surgery., Results: N = 234 participants responded to the survey (60% spine neurosurgeons; 22.6% working in private practice). Thirty-two percent reported to have more than 20 years of experience, followed by surgeons having between 5 and 10 (27.4%), 10-15 (17.9%), 15-20 (12%), and 0-5 years (10.7%). Gender distribution (12% vs 27% female gender, p = 0.04), private practice activity (28% vs 14%, p = 0.01), familiarity with the ERAS concept (57.4% vs 27%, p < 0.0001), and its implementation in the daily clinical practice (47.5% vs 18.3%, p < 0.0001) were statistically different between spine and general neurosurgeons. 54.7% of the surgeons were unfamiliar with ERAS in spine surgery. 63.7% considered ERAS as a progress; 36% declared to implement ERAS in their daily clinical practice. 1.7% reported ERAS as a decrease in the quality of management. 6.8% considered ERAS as not having an impact on patient care; 27.8% had no opinion. There were no differences in opinion on ERAS and its implementation between surgeons working in private and public hospitals. 69.5% of the spine surgeons considered ERAS having a positive impact on patient management, versus 55% of non-spine surgeons (p = 0.02)., Conclusions: Efforts are necessary to promote minimal invasive pre-, intra-, and postoperative workflow to improve patient management and reduce complications or side effects particularly adapted to spinal surgery. Specificities of spine patients, in terms of chronic pain, pre- and postoperative pain management, and psychological issues have to be considered.

Objective: Despite recently heightened advocacy efforts relating to pregnancy and family leave policies in multiple surgical specialties, no studies to date have described female neurosurgeons' experiences with childbearing. The AANS/CNS Section of Women in Neurosurgery created the Women and Pregnancy Task Force to ascertain female neurosurgeons' experiences with and attitudes toward pregnancy and the role of family leave policies., Methods: A voluntary online 28-question survey examined the pregnancy experiences of female neurosurgeons and perceived barriers to childbearing. The survey was developed and electronically distributed to all members of the American Association of Neurological Surgeons and Congress of Neurological Surgeons who self-identified as female in February 2016. Responses from female resident physicians, fellows, and current or retired practicing neurosurgeons were analyzed., Results: A total of 126 women (20.3%) responded to the survey; 57 participants (49%) already had children, and 39 (33%) planned to do so. Participants overwhelmingly had or planned to have children during the early practice and senior residency years. The most frequent obstacles experienced or anticipated included insufficient time to care for newborns (47% of women with children, 92% of women planning to have children), discrimination by coworkers (31% and 77%, respectively), and inadequate time for completion of board requirements (18% and 51%, respectively). There was substantial variability in family leave policies, and a minority of participants (35%) endorsed the presence of any formal policy at their institution. Respondents described myriad unique challenges associated with pregnancy and family leave., Conclusions: Pregnancy and family leave pose significant challenges to the recruitment, retention, and advancement of women in neurosurgery. It is thus imperative to promote clear family leave policies for trainees and practitioners, address discrimination surrounding these topics, and encourage forethought and flexibility to tackle obstacles inherent in pregnancy and the early stages of child rearing.

Objective: To determine use of magnetic resonance imaging (MRI) for management of spinal trauma as a function of the availability of an MRI scanner across AO regions., Methods: A survey regarding MRI availability and/or accessibility was conducted across 6 global AO regions. Questions were formulated to 1) evaluate availability of an MRI scanner and 2) whether the availability of an MRI scanner influenced time taken to image patients with spinal trauma. Pairwise comparison of responses among AO regions was performed., Results: The survey was sent to 5.813 AO Spine members and 561 completed surveys were obtained (Africa, 3%; Asia Pacific, 22.1%; Europe, 30.8%; Latin America, 25.7%; Middle East, 9.4%; and North America, 8.9%). On availability of MRI for spinal trauma, 31.9% reported that MRI was readily available at all times, 51.3% noted 24-hour availability, but more difficult to obtain during nighttime, and 8.7% reported not having an MRI at their hospital. On time taken to obtain scans if MRI is readily available, 32.4% responded that imaging was obtained within 1 hour, whereas 39.9% stated between 1 and 4 hours. On time taken to obtain scans when MRI is least available, 7% responded that imaging was completed within 1 hour whereas 31.4% stated between 1 and 4 hours. Responses from Latin America significantly differed (P < 0.05) from all other AO regions except Africa., Conclusions: MRI use varies across AO regions, with clinical decision making on obtaining MRI in spinal trauma being influenced heavily by the availability of an MRI scanner., (Copyright © 2020. Published by Elsevier Inc.)

Objective: Historically, women have been underrepresented in medicine but nowadays the underrepresentation is more applicable to surgical disciplines. Many efforts have been made to decrease the attrition rate of women in neurosurgery and to even career opportunities to be comparable to those of male colleagues. However, it is unclear if gender disparities occur between female and male neurosurgeons. Therefore, the aim of the current study is to identify gender differences in the professional and private life of neurosurgeons., Methods: A survey consisting of 38 questions was sent to members of the Congress of Neurological Surgeons regarding demographics, career fulfillment, private life, and parenting. Comparison between female and male respondents was made., Results: A total of 870 members filled in surveys, which were analyzed. Working full time, days worked weekly, and gross salary did not differ between male and female neurosurgeons. However, female neurosurgeons rated their career fulfillment worse than did male neurosurgeons (P < 0.001) and were less likely to choose a career as a neurosurgeon again (P < 0.001). Furthermore, female neurosurgeons were less likely to be married or to have children than were male colleagues (P < 0.001)., Conclusions: Despite efforts to increase the amount of women enrolling into neurosurgery and despite efforts to strive for equality, the results of the current study show gender disparities in professional and private careers among neurosurgeons. Practice patterns did not differ between male and female neurosurgeons, but perceptions of career and characteristics of private life did. Program directors and chairs should focus on measures to decrease gender differences and to strive for equal career satisfaction among female and male neurosurgeons., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Spine surgery is a demanding surgical specialty which requires surgeons to operate for hours on end, often compromising good posture. Sustained poor posture in the operating room (OR) can be the source of many adverse health effects on spine surgeons. This study will analyze posture of a spine surgeon in different types of spine surgery cases., Methods: Posture of a surgeon was measured using the UPRIGHT Posture Training Device. The device was worn by the surgeon in the OR through a wide variety of spine surgery cases., Results: The percent time spent slouched while performing cervical, adult deformity, and lumbar spine surgeries is 39.9, 58.9, and 38.6, respectively. For all surgeries recorded, the percent time slouched is 41.6. The average procedure time was 145.3 min, with adult deformity cases on average being the longest (245.6 min) followed by cervical (152.9 min) and then lumbar (122.5 min)., Conclusion: Poor posture while operating is very likely to occur for many spine surgeons regardless of case type. This poor posture is maintained for long periods of time given the average spine surgery procedure recorded in the study was roughly 2.5 h long. Spine surgeons should be aware of the tendency for poor posture while operating, and they should try using posture-improving techniques to maintain good spine health.

Objective: Characterize current perspectives in the surgical management of vestibular schwannoma (VS) to guide otolaryngologists in understanding United States practice patterns., Methods: A retrospective analysis of ACS-NSQIP database was performed to abstract all patients from 2008 to 2016 who underwent VS resection using ICD-9/10 codes 225.1 and D33.3, respectively. The specific surgical approach employed was identified via CPT codes 61520, 61526/61596, and 61591, which represent retrosigmoid (RS), translabyrinthine (TL) and middle cranial fossa (MCF) approaches, respectively. Analyzed outcomes include general surgical complications, total length of stay, and reoperation., Results: A total of 1671 VS cases were identified, 1266 (75.7%) were RS, 292 (17.5%) were TL, and 114 (6.8%) were MCF. The annual number of cases increased over the study period from 15 to 375, which is chiefly attributed to increased institutional participation in ACS-NSQIP. Perioperative variables including BMI ( P < .001), ASA class ( P = .004), ethnicity ( P = .008), operative time ( P < .001), and reoperation ( P < .001) were found to be statistically significant between cohorts. Increased utilization of RS approach was consistent over the entire study period, with significantly more RS performed than either TL or MCF. Finally, a statistically significant difference with respect to general surgical complication rates was not noted between surgical approaches., Conclusions: There is increased employment of RS approach for the operative management of VS, which likely is the result of increased reliance on both stereotactic radiosurgery and observation as alternative treatment strategies.

Background: Few women have ascended the professional-academic ladder to become chairs of German neurosurgical departments. Indeed, only 2 out of 36 current departmental heads are female. This study aims to assess the current representation and role of women in German neurosurgery and to identify indicators of how these aspects will progress., Methods: National statistics concerning the gender distribution of neurosurgery specialists over the past 20 y and the gender distribution across DGNC (Deutsche Gesellschaft für Neurochirurgie - German Society of Neurosurgery) membership grades from 2016 to 2018 were obtained from the Federal Statistical Office and the DGNC, respectively. Additionally, the programmes of DGNC annual meetings from 2015 to 2018 were evaluated to determine the number of presentations and speaking time awarded to male and female presenters., Results: In 2017, 19% of neurosurgical specialists were female. In the same year, overall 13% of the members of the DGNC were female. There were a higher proportion of females among extraordinary members. In the last 4 y, females were overall responsible for less than a third of presentations at the annual DGNC meetings. There was also a decrease of female participation from 2015 to 2018, with regard to both overall amount of presentations and speaking time. Female participation was overall higher for presentation types typically associated with lower academic and clinical positions and which cover shorter speaking times., Conclusions: In Germany, which has one of Europe's largest neurosurgical communities, female neurosurgeons remain a minority. Structured programmes to support gender equality and diversity could facilitate the rise of women to senior positions and close the gender gap.

Purpose: Since the introduction of run-through training in UK Neurosurgery in 2007, there has been no limit on the number of posts deaneries may apply for. The rationale for run-through training was based on the premise that the number of trainees recruited would match the number of consultant posts eight years later. There has been no formal survey of the number of consultant neurosurgeons in the UK for several years. A survey was undertaken to measure the current Neurosurgical workforce. Methods: The Specialist Advisory Committee undertook a survey to establish the current workforce and estimate how best to ensure that the correct number of trainees are being recruited. Data was also obtained from public bodies including the GMC, NHS Jobs and JCST. Results: Since 1993 the number of Neurosurgeons in UK and Ireland has increased from 132.5 to 389 whole time equivalents (4.4% curvilinear annual increase). The number of registered neurosurgical trainees fell 9% from 278 in 2012 to 248 in 2017. The number of UK graduates in Neurosurgical training has remained constant. The number of trainees failing to complete training has increased from 1.25 per annum in 2009-2012 to 5-6 in 2014-2017. The number of ST1 level trainees recruited has risen, which a fall in the number of trainees entering at the ST3 level has partially offset. The number of doctors with a CCT in Neurosurgery but no substantive consultant post has risen from 26 to 43 between 2015 and 2018. Conclusions: Neurosurgical workforce data should be collected regularly and a workforce planning process should be implemented. Consultant expansion is required to reduce the number of CCT holders without consultant jobs. The specialty should prevent any further increase in the number of trainees recruited and we should consider a marginal reduction in recruitment.

Introduction: Statutory duty of candour was introduced in November 2014 for NHS bodies in England. Contained within the regulation were definitions regarding the threshold for what constitutes a notifiable patient safety incident. However, it can be difficult to determine when the process should be implemented. The aim of this survey was to evaluate the interpretation of these definitions by British neurosurgeons., Materials and Methods: All full (consultant) members of the Society of British Neurological Surgeons were electronically invited to participate in an online survey. Surgeons were presented with 15 cases and asked to decide in the case of each one whether they would trigger the process of duty of candour. Cases were stratified according to their likelihood and severity., Results: In all, 106/357 (29.7%) members participated in the survey. Responses varied widely, with almost no members triggering the process of duty of candour in cases where adverse events were common (greater than 10% likelihood) and required only outpatient follow-up (7/106; 6.6%), and almost all members doing so in cases where adverse events were rare (less than 0.1% likelihood) and resulted in death (102/106; 96.2%). However, there was clear equipoise in triggering the process of duty of candour in cases where adverse events were uncommon (0.1-10% likelihood) and resulted in moderate harm (38/106; 35.8%), severe harm (57/106; 53.8%) or death (49/106; 46.2%)., Conclusion: There is considerable nationwide variation in the interpretation of definitions regarding the threshold for duty of candour. To this end, we propose a framework for the improved application of duty of candour in clinical practice.

Introduction: The Defense Health Agency has shifted focus of military medicine to operational readiness. As such, neurosurgery remains a critical wartime specialty. We investigate the factors impacting recruitment and retention of military neurosurgeons., Methods: Survey of military neurosurgeons was performed via the American Association of Neurological Surgeons/Congress of Neurological Surgeons Joint Committee of Military Neurosurgeons and the Council of State Neurosurgical Societies. Retention and recruitment were queried., Results: 93/119 (78.2%) current or previously affiliated military neurosurgeons would recommend service as a military neurosurgeon to a colleague. Those who felt a sense of patriotism were 4.3 times more likely to recommend military service (P = 0.027, CI 1.19-16.82). Those who developed a sense of camaraderie showed a trend to recommending military neurosurgery (P = 0.058, CI 0.95-9.78). Those with a current military obligation were.28 times (P = 0.02, CI 0.09-0.85) as likely to recommend service. Military physicians who felt a need for reform to increase salary were 2.5 times less likely to be retained., Discussion: Service in the US military is a positive experience with camaraderie, patriotism, and unique military experiences predictive of recruitment. Meanwhile, focus on pay discrepancy can result in lost retention. These factors should be explored regarding recruitment and retention of military neurosurgeons., (© Association of Military Surgeons of the United States 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Spontaneous intracerebral hemorrhage (SICH) is of high mortality and morbidity. SICH in the basal ganglia is usually attributed to chronic hypertension. Postoperative rehemorrhage is a severe complication, and it is relative to surgical techniques., Methods: A retrospective survey was conducted on 123 patients with basal ganglia SICH who received surgery from January 2015 to January 2019. Postoperative rehemorrhage within 24 hours was recorded. Preoperative clinical parameters, surgeon experience (<10 and >20 years), operation time, surgical approach, and hemostasis technique were recorded and analyzed., Results: The total postoperative rehemorrhage rate was 12.2% (15/123). The univariable analysis showed general surgeons had a higher postoperative rehemorrhage rate than experienced surgeons (30.4% vs. 8.6%, respectively; P = 0.068). The operation time (minutes) in experienced surgeons was significantly longer (164.9 ± 53.5 vs. 137.7 ± 30.8, P = 0.016), but they had a higher chance to locate the responsible vessel (74.2% vs. 40.0%, P = 0.001), respectively. Logistic analysis indicated that experienced surgeons significantly reduced the risk of rehemorrhage (odds ratio [OR], 0.242; P = 0.021). Transsylvian approach was a protective factor for postoperative rehemorrhage (OR, 0.291; P = 0.045)., Conclusions: Surgeons' experience plays the most important role in postoperative rehemorrhage. Surgeons with rich experience were willing to spend more time to achieve definitive hemostasis in operation. The use of a transsylvian approach can significantly reduce the rehemorrhage rate. Packing hemostasis with gelatin sponge may increase complications., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The scientific activity of neurosurgeons and neurosurgery residents as measured by bibliometric parameters is of increased interest. While data about academic output for neurosurgeons in the USA, the UK, and Canada have been published, no similar results for German neurosurgical residents exist. Within this study, we aim to evaluate the academic output of German neurosurgery residents in 35 academic residency programs., Methods: Data for each resident were collected from the departmental websites, Pubmed, and Scopus. Further analyses evaluated the relationship between publication productivity, sex, and academic degree (Dr. med.)., Results: Data from 424 neurosurgery residents were analyzed. A total of 1222 publications were considered. A total of 355 (29%) of the 1222 publications were first-author publications. The average number of publications per resident was 2.9; the average h-index and m-quotient was 1.1 and 0.4, respectively. There was a statistically significant difference in academic output and h-index among neurosurgical residents with a doctoral degree compared with residents without such degree (5.3 vs. 1.3, p < 0.0001 and 2.0 vs. 0.5, p < 0.0001)., Conclusion: This is the very first study evaluating the academic output of neurosurgical residents in academic neurosurgical departments in Germany.

Background: The need for neurosurgical care across the globe remains a public health issue. The creation of sustainable neurological surgery departments and training programs will be indispensable in alleviating the burden of neurological disease in low to middle income countries (LMICs)., Methods: We reviewed the history of the neurological surgery department and residency program of Santarém in the state of Pará, Brazil, from 1999 to the present. We have described the epidemiology unique to the region and provided evidence of a sustainable practice in a LMIC. The challenges, limitations, and resources were explored., Results: We have provided a historical vignette of the evolution of neurological surgery in the Brazilian Amazon, including the creation of a sustainable neurological surgery practice and accredited residency program. In addition, we assessed the neurological surgery burden and epidemiology unique to the region, with an emphasis on the community and indigenous health in this remote area. We also explored the future directions of this example, which could affect the international neurological surgery community., Conclusion: A sustainable neurosurgery practice and training program is possible in a LMIC. Training neurosurgeons in developing regions of LMICs is a sustainable method to decrease the morbidity and mortality of neurological diseases and prevent the misdistribution of physicians in a country. We encourage adaptation of sustainable neurological surgery practices in similar regions across the world to increase access to necessary neurosurgical care., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Almost one half of currently practicing physicians in Europe are women. Despite advances in access to training positions and the entry of women into neurosurgery, it has remained a male-dominated field, with an underrepresentation of female leaders. We designed a 2-part study to better understand the current situation of European female neurosurgeons., Methods: The European Association of Neurosurgical Societies and its member societies were analyzed for female participation in leadership positions. Additionally, an online survey was designed, containing 33 questions about career choice, mentorship, family planning, and perceived obstacles, for women in neurosurgery., Results: A total of 116 responses were received. Most female neurosurgeons lacked same-gender role models (76%), although most reported that having a female mentor would be important (58%). An overwhelming majority (86%) believe family planning takes on a more important role for women, and 72% reported worrying their career prospects could be negatively affected by their desire to have children. The greatest obstacle perceived was the prevailing inequality in opportunities (30%) and attaining leadership positions (24%). Most (81%) reported that women have different concerns regarding their career from men, and 72% also reported feeling at a disadvantage as a woman. Most (66%) also believe should be a "Women in Neurosurgery" committee within the European Association of Neurosurgical Societies., Conclusions: Unfortunately, a gender gap still exists in European neurosurgery. The extent thereof has not yet been systematically analyzed. Our project offers a glimpse into the inequalities and obstacles women perceive in our field; however, more comprehensive data are required., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Introduction: Surgical management strategies for glioblastoma (GBM) may differ among neurosurgeons with initial biopsy of suspected tumors and the need for early re-resection of tumors within 30 days of initial surgery. This study was initiated by the American Association of Neurological Surgeons (AANS) and Congress of Neurological Surgeons (CNS) Tumor Section's interest in understanding the rates at which pre- and post-resection procedures, specifically biopsies prior to definitive resection and early re-resections, are performed by U.S. neurosurgeons in the management of GBM., Methods: A ten-question survey was distributed to members of the AANS/CNS Tumor Section., Results: The survey response rate among AANS/CNS Tumor Section surgeons was approximately 16%. Results showed that a majority of respondents performed surgery on 11-25 GBM cases annually. Of those cases, most neurosurgeons claimed that biopsies are rarely performed prior to tumor resection, but in the < 10% of cases for which biopsies are done, common reasons are to confirm radiological findings or improve the treatment plan. Likewise, re-resections are rare, but in the < 5 cases most neurosurgeons performed annually, common reasons included incomplete initial resections, referrals for greater resection, or unspecified reasons., Conclusions: Further studies are needed to confirm the results of this study, which shows low rates of stereotactic and open biopsy and early re-resection procedures performed among neurosurgeons. These rates may help form guidelines in the treatment of GBM and encourage the use of surgical adjuncts that increase the extent of resection of these tumors, thereby reducing rates of early recurrence.

Background: Women constitute a minority (9.2%) of academic neurosurgeons. We previously found that women in academic medicine are disadvantaged in funding and career advancement opportunities. We hypothesized that women are also underrepresented at neurosurgical society conferences., Methods: Programs from the 2014-2018 meetings of the Congress of Neurological Surgeons (CNS), American Association of Neurological Surgery (AANS), and North American Skull Base Society (NASBS) were analyzed. Demographic data, including name, gender, and geographic region of practice, were collected for speaker, moderator, or leadership positions. χ 2 statistical analysis was performed for difference in gender representation across all opportunity spots., Results: In the period 2014-2018, there was no female presidents or honored guest at any academic meetings analyzed; 53.8% of executive committees comprised all men. Women often constituted a minority (<15%) of speakers and moderators at CNS, AANS, and NASBS meetings: speakers (% female, range), 8.6 (5.5-11.7), 13.6 (10.1-19.7), and 10.5 (5.6-16.6); moderators (% female, range), 7.8 (0-14.3), 23.0 (81.3-91.3), and 13.0 (8.6-18.7). Conference panels frequently comprised all men (58% CNS, 20.7% AANS, 61% NASBS). χ 2 analysis found a disparity in male and female participation across all opportunity spots (P = 0.002). Additionally, female participants are often repeated, decreasing total number of unique women participating. There was no significant increase in female participation across the study period., Conclusions: In 2014-2018, underrepresentation of women in national neurosurgical conferences either matched or exceeded the baseline gender disparity seen in academic neurosurgery. We discussed potential causes of and strategies to address these findings., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Dementia with Lewy bodies (DLB) is a progressive form of dementia, accompanied by a range of behavioural and psychological symptoms. The aim of this study was to identify current clinical practice for the treatment of DLB in Japan., Methods: We conducted a survey of medical doctors engaged in the management of dementia in Japan. Participants were divided into two groups: psychiatrists (Group P) and neurologists or neurosurgeons (Group NS). Doctors completed a questionnaire and we analysed their responses to compare the two groups with regard to diagnosis and treatment of DLB, and in particular the treatment of behavioural and psychological symptoms of dementia (BPSD)., Results: Responses suggested that Group P conducted biomarker examinations less frequently and decided on their own therapeutic strategies more frequently than did Group NS. Both groups most frequently selected hallucinations/delusions as the symptoms given highest treatment priority. More than 70% of respondents in both groups reported having difficulties in treating BPSD. Atypical antipsychotics were more frequently prescribed by Group P, but were also prescribed in 70% of patients in Group NS. A third of patients received atypical antipsychotics for more than 1 year., Conclusions: The responses to this survey highlighted the difficulties faced by clinicians managing patients with DLB and identified the need to effectively treat BPSD in such patients., (© 2019 The Authors. Psychogeriatrics published by John Wiley & Sons Australia, Ltd on behalf of Japanese Psychogeriatric Society.)

Background: Medical publications reflect the development of training, research, and health services. No objective data are available regarding neurosurgical publications from Morocco. Bibliometrics were used to evaluate the contribution of Moroccan neurosurgeons (MONSs) in neurosurgical journals worldwide and to discuss the strategies that can be applied to increase the quantity and quality of publications on this subject., Methods: A literature search of reports by MONSs was performed using the PubMed database. The number and quality of the reports were evaluated with the impact factor of the neurosurgical journals and the h-index of each first author., Results: The data from 174 identified studies reported from 1989 to 2018 were analyzed. MONSs have continued to report more studies every year worldwide. However, their contribution to neurosurgical journals has been gradually declining since 2012. Scientific publishing was limited to a few great neurosurgical departments and a few academic neurosurgeons in Morocco. Most of the reports were case reports, reported in the French language, included in non-neurosurgical journals, from single centers, and without international collaboration., Conclusions: Academic neurosurgeons in Morocco should prepare their residents and young researchers on research methodology and medical writing. Moroccan neurosurgical research should be more focused on modern neurosurgical topics by highlighting our particularities. More high level of evidence studies should be reported in English-language neurosurgical journals with a high impact factor and good scientific reputation. MONSs should continue to collaborate more often with each other and with foreign centers to further improve the quality and number of international publications, regardless of the difficulties they face., (Copyright © 2019 Elsevier Inc. All rights reserved.)