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Background: The current neurosurgical workforce is not large enough to address the significant burden of neurosurgical disease worldwide, and women are under-represented in this surgical specialty. However, trainee opportunities are particularly scarce in lower- and middle-income countries, where the burden of neurosurgical disease is high. Thus, the primary aim of this study was to assess the effects of gender and country on perceived access to neurosurgical research and mentorship opportunities., Methods: A cross-sectional survey evaluating perceived access to neurosurgical research and mentorship opportunities was distributed electronically to medical students and unspecialized residents in 10 countries (Colombia, India, Ghana, Nigeria, Saudi Arabia, Spain, Uganda, the United Kingdom, the United States, and Venezuela)., Results: 34.0% of men versus 24.9% of women reported interest in neurosurgery (P < 0.001). Only 16.1% of trainees reported adequate access to neurosurgical research opportunities, which did not vary by gender overall (P = 0.070). However, more women reported inadequate access in the United States (P = 0.038), and more men reported inadequate access in Colombia (P = 0.043). In Colombia (P < 0.001), Nigeria (P = 0.003), Saudi Arabia (P = 0.038), the United States (P = 0.004), and Venezuela (P < 0.001), a lower proportion of women than men reported ever having a neurosurgery mentor of their same gender. 59.0% of female respondents noted that having access to female neurosurgeon mentors would increase their interest in neurosurgery, compared to 28.5% of male respondents (P < 0.001)., Conclusions: More male than female medical trainees in the surveyed countries reported interest in neurosurgery. However, access to adequate neurosurgical research opportunities, although relatively low overall, did not vary by gender in most countries. Access to gender-concordant mentorship was less common for women than for men, but women expressed that enhanced access to female neurosurgeon mentors would increase their interest in the field. These findings suggest potential avenues for intervention to augment and diversify the global neurosurgical workforce., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: The prevalence, management, and outcomes of hydrocephalus remain underexplored in Africa. This study aimed to analyze demographic and clinical features, evaluate treatment strategies, and assess neurological outcomes of pediatric hydrocephalus in Africa., Methods: A systematic review of the literature using the PubMed, Google Scholar, and Web of Science electronic databases was completed according to the PRISMA guidelines to identify articles describing pediatric patients in Africa with hydrocephalus., Results: Seventy-four retrospective and prospective studies and 33 case reports involving 12,355 patients were included. In 54 retrospective articles reporting patient demographics, 53.8% (3926/7297) were male with a mean age of 12.3 months. Nineteen studies reported macrocephaly (80.2%, 1639/2043) as the most common presentation. The etiology of hydrocephalus was reported as postinfectious (41.0%, 2303/5614) across 27 articles and congenital (48.6%, 1246/2563) in 10 articles. Eleven articles reported 46.7% (609/1305) of patients had communicating hydrocephalus while 53.3% (696/1305) had obstructive hydrocephalus. Diagnostic imaging included CT (76.1%, 2435/3202; n = 29 articles), ultrasonography (72.9%, 2043/2801; n = 15 articles), and MRI (44.8%, 549/1225; n = 11 articles). In 51 articles, 83.1% (7365/8865) of patients had ventriculoperitoneal shunting (VPS) while 33 articles described 54.1% (2795/5169) receiving endoscopic third ventriculostomy (ETV) for hydrocephalus surgical management. Postoperative complications included sepsis (6.9%, 29/421; n = 4 articles), surgical site infections (5.1%, 11/218; n = 4 articles), and CSF leaks (2.0%, 15/748; n = 8 articles). Shunt-related complications included infections (4.3%, 117/2717; n = 21 articles) and blockages (4.1%, 34/829; n = 6 studies). In 15 articles, 9.0% (301/3358) of patients with shunts had revisions. The mean follow-up duration was 18.9 ± 16.7 months with an overall mortality rate of 7.4% (397/5383; n = 29 articles). In the analysis of comparative studies, the 160 patients undergoing ETV demonstrated significantly higher odds of a successful operation (OR 1.54, 95% CI 0.51-4.69; p = 0.03) and neurological improvement at last follow-up (OR 3.36, 95% CI 0.46-24.79; p < 0.01) compared with the 158 who received VPS, but no significant differences were observed for complications and mortality between the two groups (p > 0.05)., Conclusions: This review offers a comprehensive summary of pediatric hydrocephalus in Africa, highlighting shunting as the primary treatment. However, the observed variations across studies highlight the need to establish standardized guidelines for reporting patient characteristics, management strategies, and outcomes to ensure consistency and comparability in articles.

Background: Prognostic indices for patients with brain metastases (BM) are needed to individualize treatment and stratify clinical trials. Two frequently used tools to estimate survival in patients with BM are the recursive partitioning analysis (RPA) and the diagnosis-specific graded prognostic assessment (DS-GPA). Given recent advances in therapies and improved survival for patients with BM, this study aims to validate and analyze these 2 models in a modern cohort., Methods: Patients diagnosed with BM were identified via our institution's Tumor Board meetings. Data were retrospectively collected from the date of diagnosis with BM. The concordance of the RPA and GPA was calculated using Harrell's C index. A Cox proportional hazards model with backwards elimination was used to generate a parsimonious model predictive of survival., Results: Our study consisted of 206 patients diagnosed with BM between 2010 and 2019. The RPA had a prediction performance characterized by Harrell's C index of 0.588. The DS-GPA demonstrated a Harrell's C index of 0.630. A Cox proportional hazards model assessing the effect of age, presence of lung, or liver metastases, and Eastern Cooperative Oncology Group (ECOG) performance status score of 3/4 on survival yielded a Harrell's C index of 0.616. Revising the analysis with an uncategorized ECOG demonstrated a C index of 0.648., Conclusions: We found that the performance of the RPA remains unchanged from previous validation studies a decade earlier. The DS-GPA outperformed the RPA in predicting overall survival in our modern cohort. Analyzing variables shared by the RPA and DS-GPA produced a model that performed analogously to the DS-GPA., Competing Interests: The authors have no disclosures relevant to the current work, nor any true/perceived conflicts of interest. Disclosures unrelated to the current work include: P.E.F.: consultant for Monteris Medical; C.R.G.: received grants from the Robert Wood Johnson Harlod Amos Medical Faculty Development Program, the Federal Food and Drug Administration, and the NIH 1R01DE031053-01A1. Consultant for Stryker and Medtronic. Deputy Editor for Spine. Pending patents unrelated to the current work; T.J.Z.: pending patents unrelated to the current work. J.S.: pending patents unrelated to the current work. All other authors have no disclosures unrelated to the current work., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Society for Neuro-Oncology and the European Association of Neuro-Oncology. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Objective: Despite the well-known neurosurgical workforce deficit in Sub-Saharan Africa, there remains a low number of neurosurgical training programs in Nigeria. This study sought to reassess the current status of specialist neurosurgical training in the country., Methods: An electronic survey was distributed to all consultant neurosurgeons and neurosurgery residents in Nigeria. Demographic information and questions relating to the content, process, strengths, and challenges of neurosurgical training were explored as part of a broader survey assessing neurosurgical capacity. Descriptive statistics were used for analysis., Results: Respondents identified 15 neurosurgical training centers in Nigeria. All 15 are accredited by the West African College of Surgeons, and 6 by the National Postgraduate Medical College of Nigeria. The average duration of core neurosurgical training was 5 years. Some identified strengths of Nigerian neurosurgical training included learning opportunities provided to residents, recent growth in the neurosurgical training capacity, and satisfaction with training. Challenges included a continued low number of training programs compared to the population density, lack of subspecialty training programs, and inadequate training infrastructure., Conclusions: Despite the high number of neurosurgery training centers in Nigeria, compared to other West African countries, the programs are still limited in number and capacity. Although this study shows apparent trainee satisfaction with the training process and contents, multiple challenges exist. Efforts at improving training capacity should focus on continuing the development and expansion of current programs, commencing subspecialty training, driving health insurance to improve funding, and increasing available infrastructure for training., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Nigeria has an inadequate number of neurosurgeons to meet the population's demand for neurosurgical care. Furthermore, few Nigerian neurosurgeons are female. This study sought to evaluate perceived barriers to pursuing neurosurgery among Nigerian trainees., Methods: A 60-question survey was distributed electronically to medical students at the College of Medicine, University of Ibadan, and unspecialized intern physicians at the University College Hospital, Ibadan, Nigeria. Participation was voluntary., Results: One hundred fifty-seven respondents participated in the survey. A greater proportion of males indicated an interest in neurosurgery than females (40% vs. 18%, P = 0.010). Over 75% of respondents identified decreased family and personal time, long work hours, and limited access to maternity or paternity leave as potential barriers to neurosurgery, with no differences by gender. Respondents overall saw being female and low-income as disadvantageous to pursuing neurosurgery in Nigeria. Although they universally viewed research as important in neurosurgery, 59% of respondents reported inadequate access to research opportunities; this did not vary by gender. However, 65% of female respondents reported that having a female neurosurgery mentor would increase their interest in neurosurgery (vs. 37% of males, P = 0.001)., Conclusions: Nigerian medical trainees perceived the time commitment of neurosurgery as a major barrier to pursuing the specialty. Regardless of gender, they also reported low exposure to neurosurgery and inadequate access to research and mentorship opportunities. However, we found that enhanced female representation among neurosurgery mentors and improved work-life balance could increase interest in neurosurgery and help expand Nigeria's neurosurgical workforce., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: This study aims to provide a comprehensive overview of pediatric neurosurgery in Nigeria, since 1962, by assessing epidemiological data, management strategies, and case outcomes., Methods: A systematic bibliometric review of Nigerian neurosurgical literature was reported with the PRISMA guidelines. The Risk of Bias Assessment Tool was applied to all nonrandomized studies, and a descriptive analysis was performed for all variables., Results: We identified 12,295 pediatric patients from 196 published studies. Most publications (72.4%) occurred in the recent 2 decades, of which 40.3% were observational case reports/series. The patients were predominantly male (57.2%) and aged 0-18 years, with the majority (66.1%) belonging to the 0-5 age range. Most patients (63.4%) presented between 1-12 months. The most common presenting feature was altered consciousness (7.7%), with computed tomography (38.8%) being the most frequently utilized diagnostic imaging modality. The diagnoses with the greatest prevalence (60.2%) were congenital abnormalities such as hydrocephalus and neural tube defects. 57.5% of cases received surgical therapy, with ventriculoperitoneal shunt placement being the most noticeable procedure performed (36.4%). Complications were identified in 9.5% of cases, with a 4.5% death rate. The Glasgow Outcome Score (95.7%) was the primary outcome measure utilized, with positive outcomes reported in 59.3% of cases., Conclusions: This review provides significant epidemiological data which emphasizes the country's enormous burden of pediatric neurosurgical cases. The findings can help guide clinical decisions as well as future research and policy development., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: This study investigates the scope, trends, and challenges of neurosurgical research in Nigeria since inception of the specialty in 1962., Methods: A bibliometric review of the neurosurgical literature from Nigeria was performed. Variables extracted included year and journal of publication, article topic, article type, research type, study design, article focus area, and limitations. Descriptive and quantitative analyses were performed for all variables. Trends of research publications were described in three periods: pioneering (1962-1981), recession (1982-2001), and resurgent (2002-2021)., Results: Of the 1023 included articles, 10.0% were published in the pioneering period, 9.2% in the recession period, and 80.8% in the resurgent period. Papers were predominantly published in World Neurosurgery (4.5%) and Nigerian Journal of Clinical Practice (4.0%). A total of 79.9% of the 4618 authors were from Nigerian institutions; 86.3% of the articles covered clinical research and were mainly focused on service delivery and epidemiology (89.9%). The most prominent topics were traumatic brain injury (25.8%) and central nervous system malignancy (21.4%). Only 4.4% of the publications received funding, mostly from agencies in the United States (31.7%). Barriers to neurosurgical research included lack of clinical databases (18.0%), increasing burden of disease (12.5%), and diagnostic challenges (12.4%)., Conclusions: Neurosurgical research in Nigeria continues to grow due to increased training, workforce, and infrastructural improvements. Addressing the major challenges through establishment of research databases, development of evidence-based management guidelines, and increasing research training, funding and opportunities can increase research capacity in Nigeria., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: Neurotrauma is a significant cause of morbidity and mortality in Nigeria. We conducted this systematic review to generate nationally generalizable reference data for the country., Methods: Four research databases and gray literature sources were electronically searched. Risk of bias was assessed using the Risk of Bias in Non-Randomized Studies of Interventions and Cochrane's risk of bias tools. Descriptive analysis, narrative synthesis, and statistical analysis (via paired t-tests and χ 2 independence tests) were performed on relevant article metrics (α = 0.05)., Results: We identified a cohort of 45,763 patients from 254 articles. The overall risk of bias was moderate to high. Most articles employed retrospective cohort study designs (37.4%) and were published during the last 2 decades (81.89%). The cohort's average age was 32.5 years (standard deviation, 20.2) with a gender split of ∼3 males per female. Almost 90% of subjects were diagnosed with traumatic brain injury, with road traffic accidents (68.6%) being the greatest cause. Altered consciousness (48.4%) was the most commonly reported clinical feature. Computed tomography (53.5%) was the most commonly used imaging modality, with skull (25.7%) and vertebral fracture (14.1%) being the most common radiological findings for traumatic brain injury and traumatic spinal injury, respectively. Two-thirds of patients were treated nonoperatively. Outcomes were favorable in 63.7% of traumatic brain injury patients, but in only 20.9% of traumatic spinal injury patients. Pressure sores, infection, and motor deficits were the most commonly reported complications in the latter., Conclusions: This systematic review and pooled analysis demonstrate the significant burden of neurotrauma across Nigeria., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: Spinal pathologies are prevalent in Nigeria, though epidemiological data remains sparse. This systematic review used pooled patient-level data from across the country to generate a standardized epidemiological reference., Methods: Four research databases and gray literature sources were searched. Risk of bias assessment was conducted using Risk of Bias in Non-Randomised Studies - of Interventions and Cochrane's risk of bias tool. We descriptively analyzed all article metrics and statistically analyzed relevant data variables via paired t-test and χ 2 independence tests (α = 0.05)., Results: One hundred twenty-seven articles, comprising a patient cohort of 8425 patients, were analyzed. Most were retrospective cohort studies (46.5%) and case reports/series (31.5%), with an overall moderate-high risk of bias. Most studies were published in the last 20 years. Most patients were male (∼2.5 males per female), with an average age of 43.2 years (±16.4). Clinical diagnoses spanned the breadth of spinal neurosurgery. Approximately 45.0% of patients had complete spinal impairment. Pain (41.7%) was the most reported presenting feature. X-ray (45.1%) was the most common investigation used. Intervertebral disc herniation (18.9%) was the most prevalent imaging finding on MRI. Most patients were managed nonoperatively (57.8%), with a favorable outcome in 27.4% of patients. Posttreatment complications included pressure sores, infection, and motor deficits., Conclusions: This systematic review and pooled analysis provide an epidemiological overview of spinal neurosurgery in Nigeria over the last 60 years and serves as a useful reference to direct future global research in this arena., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: Vascular neurosurgery has developed significantly in Nigeria, but its burden and challenges remain unclear. This study systematically reviewed vascular neurosurgical literature from Nigeria., Methods: Four research databases and gray literature sources were searched from 1962-2021. ROBINS-I tool was used to assess risk of bias. Descriptive, narrative, and statistical analyses were conducted on all variables. Where appropriate, paired t-tests and Chi-squared independence tests were used (α = 0.05)., Results: 56 articles were included and 3203 patients pooled for analysis. Risk of bias was moderate-high. Most articles were published over the last 20 years with retrospective cohort studies and case reports being the most common study designs. The cohort had a relatively even gender split and an average age of 49 years (±22). Cerebrovascular accidents accounted for over 85% of diagnoses, with most etiologies being traumatic. Headache and motor deficit were the most prevalent clinical features. X-ray and carotid angiography were the most commonly reported imaging modalities, closely followed by computed tomography (CT) and CT angiography. The top two radiological diagnoses were ischemic cerebrovascular disease and intracerebral hematoma. Aneurysmal clipping and hematoma evacuation were the most commonly reported treatment modalities. Outcome at last follow-up was favorable in 48%. The mortality rate was 6%. Post-treatment complications included chest infection and rebleeding., Conclusions: This study illustrates the epidemiological burden of neurovascular pathology (based on the available data in published literature) in Nigeria, and raises awareness amongst service providers and researchers of the attendant challenges and epochal trends seen within vascular neurosurgery in Nigeria., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: Access to neuro-oncologic care in Nigeria has grown exponentially since the first reported cases in the mid-1960s. In this systematic review and pooled analysis, we characterize the growth of neurosurgical oncology in Nigeria and build a reference paper to direct efforts to expand this field., Methods: We performed an initial literature search of several article databases and gray literature sources. We included and subsequently screened articles published between 1962 and 2021. Several variables were extracted from each study, including the affiliated hospital, the number of patients treated, patient sex, tumor pathology, the types of imaging modalities used for diagnosis, and the interventions used for each individual. Change in these variables was assessed using Chi-squared independence tests and univariate linear regression when appropriate., Results: A total of 147 studies were identified, corresponding to 5,760 patients. Over 4000 cases were reported in the past 2 decades from 21 different Nigerian institutions. The types of tumors reported have increased over time, with increasingly more patients being evaluated via computed tomography (CT) and magnetic resonance imaging (MRI). There is also a prevalent use of radiotherapy, though chemotherapy remains an underreported treatment modality., Conclusions: This study highlights key trends regarding the prevalence and management of neuro-oncologic pathologies within Nigeria. Further studies are needed to continue to learn and guide the future growth of this field in Nigeria., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Although women have made remarkable strides in several medical specialties in Sub-Saharan Africa, their presence and contribution to the development of neurosurgery remain limited. We sought to study the gender differences within Nigerian neurosurgery, identify challenges resulting from these differences, and recommend how African female neurosurgeons can maximize their effects in neurosurgery., Methods: A structured online survey captured data on neurosurgical infrastructural capacity, workforce, and training from neurosurgical consultants and residents in neurosurgical centers in Nigeria. All the collected data were coded and analyzed., Results: Altogether, 82 neurosurgical consultants and 67 neurosurgical residents from 50 primary medical institutions in Nigeria completed the online survey. Only 8 of the respondents (5.4%) were women, comprising 3 consultants, 2 senior residents, and 3 junior residents. Although 40.2% of the respondents did not believe that being female affected the decision of whether to specialize in neurosurgery, 46.3% believed that being female was a disadvantage. Most did not believe that being female affected admission (57.8%), completion of a neurosurgery residency (58.5%), or life working as a neurosurgeon after graduation (63.4%). The most common challenges women face while navigating through neurosurgery training and practice are erosion of family and social life, lack of female mentors, and lack of a work-life balance., Conclusions: There is a deficit of both female consultants and trainees among Nigerian neurosurgeons. Identifying female medical students with a strong interest in neurosurgery and providing early mentorship might increase the number of female neurosurgeons., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: There has been a modest but progressive increase in the neurosurgical workforce, training, and service delivery in Nigeria in the last 2 decades. However, these resources are unevenly distributed. This study aimed to quantitatively assess the availability and distribution of neurosurgical resources in Nigeria while projecting the needed workforce capacity up to 2050., Methods: An online survey of Nigerian neurosurgeons and residents assessed the country's neurosurgical infrastructure, workforce, and resources. The results were analyzed descriptively, and geospatial analysis was used to map their distribution. A projection model was fitted to predict workforce targets for 2022-2050., Results: Out of 86 neurosurgery-capable health facilities, 65.1% were public hospitals, with only 17.4% accredited for residency training. Dedicated hospital beds and operating rooms for neurosurgery make up only 4.0% and 15.4% of the total, respectively. The population disease burden is estimated at 50.2 per 100,000, while the operative coverage was 153.2 cases per neurosurgeon. There are currently 132 neurosurgeons and 114 neurosurgery residents for a population of 218 million (ratio 1:1.65 million). There is an annual growth rate of 8.3%, resulting in a projected deficit of 1113 neurosurgeons by 2030 and 1104 by 2050. Timely access to neurosurgical care ranges from 21.6% to 86.7% of the population within different timeframes., Conclusions: Collaborative interventions are needed to address gaps in Nigeria's neurosurgical capacity. Investments in training, infrastructure, and funding are necessary for sustainable development and optimized outcomes., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: Despite 6 decades of existence, neurosurgery is still in the developing stages in Nigeria. In this era of collaborative health system capacity-building in low- and middle-income countries, this article reviews past efforts and future prospects for collaborative neurosurgical development in Nigeria., Methods: A bibliometric review of the Nigerian neurosurgical literature and data from a structured survey of Nigerian neurosurgeons and residents provided details of current local and international collaborations for neurosurgical research, service delivery, training, and capacity building. These were analyzed to provide an overview of the role of collaborations in sustainable neurosurgical development in Nigeria and to recommend approaches to enhance neurosurgical capacity., Results: In 1023 peer-reviewed neurosurgery publications from Nigeria, there were 4618 authors with 3688 from 98 Nigerian institutions and 930 from 296 foreign institutions in 70 countries. While there were significant research collaborations amongst Nigerian institutions, the most common were with institutions in the US, United Kingdom, and Cameroon. From the survey, 62 of 149 respondents (41.6%) from 32 health facilities noted their institution's involvement in capacity-building neurosurgical collaborations. These collaborations involved 22 Nigerian institutions and 13 foreign institutions in 9 countries and were mostly for training and workforce development (78.1%), and research and data management (59.4%). The majority of foreign institutions were from the US and United Kingdom., Conclusions: Current and previous neurosurgical collaborations have led to sustainable progress in Nigeria. Further local, regional, and international collaborations would enhance the capacity to address the needs and challenges affecting neurosurgery in Nigeria., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Like many low- and-middle-income countries in Africa, documented assessment of the neurosurgical workforce, equipment, infrastructure, and scope of service delivery in Nigeria is lacking. This study aimed to assess the capacity for the delivery of neurosurgical services in Nigeria., Methods: An 83-question survey was disseminated to neurosurgeons and residents in Nigeria. We report the findings from the capacity assessment section of the survey, which used the modified neurological-PIPES (personnel, infrastructure, procedures, equipment, and supplies) (MN-PIPES) tool to evaluate the availability of neurosurgical personnel, infrastructure, procedures, equipment, and supplies. A comparative analysis was done using the domain and total MN-PIPES scores and MN-PIPES index., Results: The national average MN-PIPES score and index were 176.4 and 9.8, respectively. Overall, the southwest and northwest regions had the highest scores and frequently had high subscores. The survey respondents reported that the main challenges impeding neurosurgery service delivery were a lack of adjunctive supplies (75.2%), a dearth of diagnostic and interventional equipment (72.4%), and an absence of a dedicated intensive care unit (72.4%)., Conclusions: The availability of workforce, infrastructure, equipment, and supplies needed to provide optimal neurosurgical care is uneven in many institutions in Nigeria. Although major strides have been made in recent years, targeted collaborative interventions at local, national, regional, and international levels will further improve neurosurgical service delivery in Nigeria and will have positive ripple effects on the rest of the healthcare system., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: To investigate differences in sociodemographic characteristics and short-term outcomes between patients undergoing prenatal versus postnatal myelomeningocele repair., Methods: Patients who underwent myelomeningocele repair at our institution were stratified based on prenatal or postnatal timing of repair. Baseline characteristics and outcomes were compared. Multivariate analysis was performed to identify whether prenatal repair was a predictor of outcomes independent of socioeconomic measures., Results: 49 patients underwent postnatal repair, and 30 underwent prenatal repair. Patients who underwent prenatal repair were more likely to have private insurance (73.3% vs. 42.9%, p = 0.03) and live farther from the hospital where they received their repair (251.5 ± 447.4 vs. 72.5 ± 205.6 miles, p = 0.02). Patients who underwent prenatal repair had shorter hospital stays (14.3 ± 22.7 days vs. 25.3 ± 20.1 days, p = 0.03), fewer complications (13.8% vs. 42.9%, p = 0.01), fewer 30-day ED visits (0.0% vs. 34.0%, p < 0.001), lower CSF diversion rates (13.8% vs. 38.8%, p = 0.02), and better functional status at 3-months (13.3% vs. 57.1% delayed, p = 0.009), 6-months (20.0% vs. 56.7% delayed, p = 0.03), and 1-year (29.4% vs. 70.6% delayed, p = 0.007). On multivariate analysis, prenatal repair was an independent predictor of inpatient complication (OR(95%CI): 0.19(0.05-0.75), p = 0.02) and 3-month (OR(95%CI): 0.14(0.03-0.80) p = 0.03), 6-month (OR(95%CI): 0.12(0.02-0.73), p = 0.02), and 1-year (OR(95%CI): 0.19(0.05-0.80), p = 0.02) functional status., Conclusion: Prenatal repair for myelomeningocele is associated with better outcomes and developmental functional status. However, patients receiving prenatal closure are more likely to have private health insurance and live farther from the hospital, suggesting potential barriers to care., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background and Objectives: Low- and middle-income countries (LMICs) face higher incidences and burdens of care for neural tube defects (NTDs) and hydrocephalus compared with high-income countries (HICs), in part due to limited access to neurosurgical intervention. In this scoping review, we aim to integrate studies on prenatal care, counseling, and surgical management for families of children with spinal dysraphism and hydrocephalus in LMICs and HICs., Methods: PubMed, Embase, Global Index Medicus, and Web of Science electronic databases were searched for English language articles pertaining to prenatal care, counseling, and surgical management for families of children with spinal dysraphism and hydrocephalus in HICs and LMICs. Identified abstracts were screened for full-text review. Studies meeting inclusion criteria were reviewed in full and analyzed., Results: Seventy studies met the inclusion criteria. Twelve studies (16.9%) were conducted in HICs only, 50 studies (70.4%) were conducted in LMICs only, and 9 studies (12.7%) encompassed both. On thematic analysis, seven underlying topics were identified: epidemiology, folate deficiency and supplementation/fortification, risk factors other than folate deficiency, prenatal screening, attitudes and perceptions about NTDs and their care, surgical management, and recommendations for guideline implementation., Conclusion: NTDs have become a widely acknowledged public health problem in many LMICs. Prenatal counseling and care and folate fortification are critical in the prevention of spinal dysraphism. However, high-quality, standardized studies reporting their epidemiology, prevention, and management remain scarce. Compared with NTDs, research on the prevention and screening of hydrocephalus is even further limited. Future studies are necessary to quantify the burden of disease and identify strategies for improving global outcomes in treating and reducing the prevalence of NTDs and hydrocephalus. Surgical management of NTDs in LMICs is currently limited, but pediatric neurosurgeons may be uniquely equipped to address disparities in the care and counseling of families of children with spinal dysraphism and hydrocephalus., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Background: Spinal arachnoid webs (SAWs) are rare pathologies of the spinal meninges often associated with syringomyelia and the radiographic "scalpel sign." Patients can experience pain, numbness, gait disturbances, or no symptoms at all. They are typically diagnosed via magnetic resonance imaging and treated with laminectomy and excision., Observations: A 61-year-old male presented after a mechanical fall and had an incidentally discovered SAW on imaging. He was initially asymptomatic and was therefore conservatively managed. Several years later, however, the patient experienced new-onset back pain, paresthesia, and balance problems, with interval imaging demonstrating worsening of the edema surrounding his SAW. The patient subsequently underwent resection of the SAW, which led to significant resolution of his symptoms., Lessons: An SAW can be asymptomatic or can manifest with a wide variety of symptoms. When this condition is incidentally discovered in asymptomatic patients, neurosurgeons should guide these patients to follow-up urgently if they develop any neurological symptoms. At that time, further imaging can be performed to determine if surgical treatment is indicated. Although SAW is rare, clinicians should be aware of the signs and symptoms, because prompt surgical intervention can significantly improve neurological symptoms.

Background: Intraoperative neurosurgical adjuncts improve extent of resection whilst mitigating patient morbidity. The delivery of neurosurgical care via these adjuncts is the norm in high-income countries, but there is yet to be a study highlighting the usage of neurosurgical oncology adjuncts in Africa. This paper aims to provide awareness of the use of these adjuncts in Africa, reasons for limited procurement, and possible solutions to the problem., Methods: This scoping review was conducted in accordance with Preferred Reporting Items for Systematic Review and Meta-Analysis Extension for Scoping Reviews guidelines. Semantic derivatives of neurosurgical oncology, adjuncts, and Africa were applied to medical databases. Studies in Africa with outcomes relating to adjunct usage, morbidity, mortality, and quality of life were selected. Book chapters and reviews were excluded., Results: Thirteen studies with 287 patients (0.5 to 74 years) were included in the final analysis. Most studies were cohort observational (46.2%) and originated from South Africa (46.2%). Meningioma was the most prevalent tumor histology (39.4%), and neuronavigation was the most readily used adjunct for surgical resection (30.8%). Using adjuncts, gross total resection was achieved in close to half the patient cohort (49.8%). Limited technology, lack of experience, cost of equipment, and inconsistency in power supply were noted as factors contributing to lack of adjunct usage., Conclusions: Neurosurgical adjuncts provide significant benefits in neurosurgical oncology. There is limited utilization of intraoperative adjuncts in most of Africa owing to limited resources and experienced professionals. Bilateral partnerships with a focus on donation and education will foster safe and sustainable adjunct incorporation in Africa., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Spinal cord ependymomas (SCEs) represent the most common intramedullary spinal cord tumors among adults. Research shows that access to neurosurgical care and patient outcomes can be greatly influenced by patient location. This study investigates the association between the outcomes of patients with SCE in metropolitan and nonmetropolitan areas., Methods: Cases of SCE between 2004 and 2019 were identified within the Central Brain Tumor Registry of the United States, a combined dataset including the Centers for Disease Control and Prevention's National Program of Cancer Registries and National Cancer Institute's Surveillance, Epidemiology, and End Results Program data. Multivariable logistic regression models were constructed to evaluate the association between urbanicity and SCE treatment, adjusted for age at diagnosis, sex, race and ethnicity. Survival data was available from 42 National Program of Cancer Registries (excluding Kansas and Minnesota, for which county data are unavailable), and Cox proportional hazard models were used to understand the effect of surgical treatment, county urbanicity, age at diagnosis, and the interaction effect between age at diagnosis and surgery, on the survival time of patients., Results: Overall, 7577 patients were identified, with 6454 (85%) residing in metropolitan and 1223 (15%) in nonmetropolitan counties. Metropolitan and nonmetropolitan counties had different age, sex, and race/ethnicity compositions; however, demographics were not associated with differences in the type of surgery received when stratified by urbanicity. Irrespective of metropolitan status, individuals who were American Indian/Alaska Native non-Hispanic and Hispanic (all races) were associated with reduced odds of receiving surgery. Individuals who were Black non-Hispanic and Hispanic were associated with increased odds of receiving comprehensive treatment. Diagnosis of SCE at later ages was linked with elevated mortality (hazard ratio = 4.85, P < 0.001). Gross total resection was associated with reduced risk of death (hazard ratio = 0.37, P = 0.004), and age did not interact with gross total resection to influence risk of death., Conclusions: The relationship between patients' residential location and access to neurosurgical care is critical to ensuring equitable distribution of care. This study represents an important step in delineating areas of existing disparities., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: Racial disparities are ubiquitous across medicine in the US. This study aims to assess the evidence of racial disparities within neurosurgery and across its subspecialties, with a specific goal of quantifying the distribution of articles devoted to either identifying, understanding, or reducing disparities., Methods: The authors searched the MEDLINE, EMBASE, and Scopus databases by using keywords to represent the concepts of neurosurgery, patients, racial disparities, and specific study types. Two independent reviewers screened the article titles and abstracts for relevance. A third reviewer resolved conflicts. Data were then extracted from the included articles and each article was categorized into one of three phases: identifying, understanding, or reducing disparities. This review was conducted in accordance with the PRISMA Extension for Scoping Reviews (PRISMA-ScR) guidelines., Results: Three hundred seventy-one studies published between 1985 and 2023 were included. The distribution of racial disparities literature was not equally spread among specialties, with spine representing approximately 48.3% of the literature, followed by tumor (22.1%) and general neurosurgery (12.9%). Most studies were dedicated to identifying racial disparities (83.6%). The proportion of literature devoted to understanding and reducing disparities was much lower (15.1% and 1.3%, respectively). Black patients were the most negatively impacted racial/ethnic group in the review (63.3%). The Hispanic or Latino ethnic group was the second most negatively impacted (25.1%). The following categories-other outcomes (28.0%), the offering of treatment (21.6%), complications (18.6%), and survival (16.7%)-represented the most frequently measured outcomes., Conclusions: Although strides have been taken to identify racial disparities within neurosurgery, fewer studies have focused on understanding and reducing these disparities. The tremendous rise of literature within this domain but the relative paucity of solutions necessitates the study of targeted interventions to provide equitable care for all patients undergoing neurosurgical treatment.

Competing Interests: The authors have no financial or other competing interests to disclose, and the work is not under consideration for publication by any other journal or in any other form.

Background: The management of spinal cord astrocytomas (SCAs) remains controversial and may include any combination of surgery, radiation, and chemotherapy. Factors such as urbanicity (metropolitan versus non-metropolitan residence) are shown to be associated with patterns of treatment and clinical outcomes in a variety of cancers, but the role urbanicity plays in SCA treatment remains unknown., Methods: The Central Brain Tumor Registry of the United States (CBTRUS) analytic dataset, which combines data from CDC's National Program of Cancer Registries (NPCR) and NCI's Surveillance, Epidemiology, and End Results Programs, was used to identify individuals with SCAs between 2004 and 2019. Individuals' county of residence was classified as metropolitan or non-metropolitan. Multivariable logistic regression models were used to evaluate associations between urbanicity and SCA. Cox proportional hazard models were constructed to assess the effect of urbanicity on survival using the NPCR survival dataset (2004-2018)., Results: 1697 metropolitan and 268 non-metropolitan SCA cases were identified. The cohorts did not differ in age or gender composition. The populations had different racial/ethnic compositions, with a higher White non-Hispanic population in the non-metropolitan cohort (86 % vs 66 %, p < 0.001) and a greater Black non-Hispanic population in the metropolitan cohort (14 % vs 9.9 %, p < 0.001). There were no significant differences in likelihood of receiving comprehensive treatment (OR=0.99, 95 % CI [0.56, 1.65], p = >0.9), or survival (hazard ratio [HR]=0.92, p = 0.4) when non-metropolitan and metropolitan cases were compared. In the metropolitan cohort, there were statistically significant differences in SCA treatment patterns when stratified by race/ethnicity (p = 0.002)., Conclusions: Urbanicity does not significantly impact SCA management or survival. Race/ethnicity may be associated with likelihood of receiving certain SCA treatments in metropolitan communities., Competing Interests: Declaration of Competing Interest JSB-S is a full-time employee of the NIH/NCI. GC and KAW are full-time contractors of the NIH/NCI. CRG received grants from the Robert Wood Johnson Harold Amos Medical Faculty Development Program, the Federal Food and Drug Administration, and is a Consultant for Medtronic and Stryker. ME received a Medtronic Honorarium and Fellowship Funding, Depuy Synthes Honorarium, Globus Honorarium, and Restore3D Consulting and Shares., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: Lipomyelomeningoceles (LMMs) are subcutaneous lipomas with dural penetration that often present with spinal cord tethering and may lead to neurological deterioration if untreated. This report describes a rare case of an LMM associated with immature nephroblastic tissue, representing a nephrogenic rest (NR) or, less likely, an immature teratoma., Clinical Presentation: An 8-day-old infant girl presented to the clinic with a sacral dimple. Imaging demonstrated a tethered spinal cord with low-lying conus medullaris and an LMM. A firm mass was noted in the subcutaneous lipoma. Detethering surgery and removal of the lipoma and mass were performed at the age of 6 months. Pathological examination identified the mass as cartilage, fat, and immature nephroblastic tissue consistent with NR tissue or, less likely, a teratoma with renal differentiation., Conclusion: This presentation of an LMM associated with an immature teratoma or NR poses a risk of malignant transformation in patients. As a result, careful surgical dissection, resection, and close clinical follow-up are recommended for these patients., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Neurosurgical capacity building efforts attempt to address the shortage of neurosurgeons and lack of neurosurgical capacity in low- and middle-income countries. This review sought to characterize neurosurgical capacity building efforts in low- and middle-income countries and the challenges they face, and identify factors that predict higher engagement, better training, and performance of high-impact activities., Methods: A scoping review using PubMed and Embase databases was performed and relevant articles were identified. Programs were classified into 6 categories and the activities they performed were classified as having a high-, medium-, or mild impact on capacity. Programs were also classified using the Olivieri engagement and training criteria., Results: Fifty-seven articles representing 42 unique efforts were included. The most important determinant of impact was a program's design and intent. Furthermore, 91% of training and twinning programs received high (class 2 or 3) engagement classifications compared to 17% of mission trips and training camps (P < 0.001); 91% of training and twinning programs received high training classifications compared to 64% of mission trips and training camps (P = 0.015); and 91% of training and twinning programs reported performing high-impact activities compared to 29% of mission trips and training camps (P < 0.001)., Conclusions: Training and twinning programs are more engaged, offer better training, and are more likely to perform high-impact activities compared to mission trips and training camps, suggesting that these types of programs offer the greatest chance of producing substantial and sustainable improvements to neurosurgical capacity., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: The rates of women and underrepresented racial and ethnic minority (UREM) students successfully matching into neurosurgical residency are extremely low and do not reflect the makeup of the general population. As of 2019, only 17.5% of neurosurgical residents in the United States were women, 4.95% were Black or African American, and 7.2% were Hispanic or Latinx. Earlier recruitment of UREM students will help to diversify the neurosurgical workforce. Therefore, the authors developed a virtual educational event for undergraduate students entitled "Future Leaders in Neurosurgery Symposium for Underrepresented Students'' (FLNSUS). The primary objectives of the FLNSUS were to expose attendees to 1) neurosurgeons from diverse gender, racial, and ethnic backgrounds; 2) neurosurgical research; 3) opportunities for neurosurgical mentorship; and 4) information about life as a neurosurgeon. The authors hypothesized that the FLNSUS would increase student self-confidence, provide exposure to the specialty, and reduce perceived barriers to a neurosurgical career., Methods: To measure the change in participant perceptions of neurosurgery, pre- and postsymposium surveys were administered to attendees. Of the 269 participants who completed the presymposium survey, 250 participated in the virtual event and 124 completed the postsymposium survey. Paired pre- and postsurvey responses were used for analysis, yielding a response rate of 46%. To assess the impact of participant perceptions of neurosurgery as a field, pre- and postsurvey responses to questions were compared. The change in response was analyzed, and a nonparametric sign test was performed to check for significant differences., Results: According to the sign test, applicants showed increased familiarity with the field (p < 0.001), increased confidence in their abilities to become neurosurgeons (p = 0.014), and increased exposure to neurosurgeons from diverse gender, racial, and ethnic backgrounds (p < 0.001 for all categories)., Conclusions: These results reflect a significant improvement in student perceptions of neurosurgery and suggest that symposiums like the FLNSUS may promote further diversification of the field. The authors anticipate that events promoting diversity in neurosurgery will lead to a more equitable workforce that will ultimately translate to enhanced research productivity, cultural humility, and patient-centered care in neurosurgery.

The movement to decolonize global health challenges clinicians and researchers of sub-disciplines, like global neurosurgery, to redefine their field. As an era of racial reckoning recentres the colonial roots of modern health disparities, reviewing the historical determinants of these disparities can constructively inform decolonization. This article presents a review and analysis of the historical determinants of neurosurgical inequities as understood by a group of scholars who share Sub-Saharan African descent. Vignettes profiling the colonial histories of Cape Verde, Rwanda, Cameroon, Ghana, Brazil, and Haiti illustrate the role of the colonial legacy in the currently unmet need for neurosurgical care in each of these nations. Following this review, a bibliographic lexical analysis of relevant terms then introduces a discussion of converging historical themes, and practical suggestions for transforming global neurosurgery through the decolonial humanism promulgated by anti-racist practices and the dialogic frameworks of conscientization., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Barthélemy et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Prompt surgical decompression after traumatic spinal cord injury (TSCI) may be associated with improved sensorimotor outcomes. Delays in presentation may prevent timely decompression after TSCI., Objective: To systematically review existing studies investigating delays in presentation after TSCI in low- and middle-income countries (LMICs) and high-income countries (HICs)., Methods: A systematic review was conducted and studies featuring quantitative or qualitative data on prehospital delays in TSCI presentation were included. Studies lacking quantitative or qualitative data on prehospital delays in TSCI presentation, case reports or series with <5 patients, review articles, or animal studies were excluded from our analysis., Results: After exclusion criteria were applied, 24 studies were retained, most of which were retrospective. Eleven studies were from LMICs and 13 were from HICs. Patients with TSCI in LMICs were younger than those in HICs, and most patients were male in both groups. A greater proportion of patients with TSCI in studies from LMICs presented >24 hours after injury (HIC average proportion, 12.0%; LMIC average proportion, 49.9%; P = 0.01). Financial barriers, lack of patient awareness and education, and prehospital transportation barriers were more often cited as reasons for delays in LMICs than in HICs, with prehospital transportation barriers cited as a reason for delay by every LMIC study included in this review., Conclusions: Disparities in prehospital infrastructure between HICs and LMICs subject more patients in LMICs to increased delays in presentation to care., (Copyright © 2022. Published by Elsevier Inc.)

Background: Research serves to bolster clinical neurosurgery by critically assessing various disease pathologies, while identifying important challenges and opportunities. However, there is limited information on the landscape of the Ghanaian neurosurgical literature., Methods: A scoping review and bibliometric analysis was conducted in accordance with PRISMA guidelines. PubMed, Embase, Global Index Medicus, and Web of Science electronic databases were searched from inception until December 21, 2021 for English language articles about neurosurgery in Ghana., Results: 927 articles were identified and 66 were ultimately included in the analysis. A majority of them, 42.4%, were retrospective cohort studies, with 62.1% published after 2010. There were no randomized controlled or basic science studies. Most articles were published in the West African Journal of Medicine (24.2%) and non-infectious/non-traumatic spinal pathology was the most commonly discussed topic (22.7%); 66.7% of articles included only authors affiliated with Ghanaian institutions, and international collaborators frequently originated from the United States (15.9%). Only 22.7% of the manuscripts reported a funding source. Commonly reported challenges included limited sample sizes, delays in diagnosis and treatment, and lack of proper diagnostic tools and specialized care., Conclusions: This review revealed that while the Ghanaian academic neurosurgery output has been increasing over time, these have been limited to cohort studies largely assessing spine pathology. The Ghanaian neurosurgical research environment may be bolstered by an increase in research funding, the establishment of longitudinal clinical databases, training in research methodology, increased incentives for researchers, strengthening of research collaborative networks, and increased engagement of neurosurgical trainees in research., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objects accidentally left behind in the brain following neurosurgical procedures may lead to life-threatening health complications and invasive reoperation. One of the most commonly retained surgical items is the cotton ball, which absorbs blood to clear the surgeon's field of view yet in the process becomes visually indistinguishable from the brain parenchyma. However, using ultrasound imaging, the different acoustic properties of cotton and brain tissue result in two discernible materials. In this study, we created a fully automated foreign body object tracking algorithm that integrates into the clinical workflow to detect and localize retained cotton balls in the brain. This deep learning algorithm uses a custom convolutional neural network and achieves 99% accuracy, sensitivity, and specificity, and surpasses other comparable algorithms. Furthermore, the trained algorithm was implemented into web and smartphone applications with the ability to detect one cotton ball in an uploaded ultrasound image in under half of a second. This study also highlights the first use of a foreign body object detection algorithm using real in-human datasets, showing its ability to prevent accidental foreign body retention in a translational setting., Competing Interests: HB is a paid consultant to Insightec and chairman of the company’s Medical Advisory Board. Insightec is developing focused ultrasound treatments for brain tumors. This arrangement has been reviewed and approved by the Johns Hopkins University in accordance with its conflict-of-interest policies. HB has research Funding from NIH, Johns Hopkins University, and philanthropy. HB is also a consultant for CraniUS, Candel Therepeutics, Inc., InSightec*, Accelerating Combination Therapies*, Catalio Nexus Fund II, LLC*, LikeMinds, Inc*, Galen Robotics, Inc.* and Nurami Medical* (*includes equity or options). AM teaches and consults for BK Medical., (© 2022 Abramson, Curry, Mess, Thombre, Kempski-Leadingham, Mistry, Somanathan, Roy, Abu-Bonsrah, Coles, Doloff, Brem, Theodore, Huang and Manbachi.)

Background: Low- and middle-income countries experience numerous challenges in the provision of neurosurgical care. However, limited information exists on the neurosurgical workforce and the constraints under which care is delivered in Ghana, West Africa., Methods: A 19-item survey assessing neurosurgical workforce, infrastructure, and education was administered to Ghanaian consultant neurosurgeons and neurosurgeon trainees between November 8, 2021, and January 20, 2022. The data were analyzed using summary descriptions, and qualitative data were categorized into themes., Results: There were 25 consultant neurosurgeons and 8 neurosurgical trainees (from 2 training centers) identified at 11 hospitals in Ghana totaling a workforce density of 1 neurosurgeon per 1,240,000. Most neurosurgical centers were located in Accra, the capital city. Almost half of the population did not have access to a hospital with a neurosurgeon in their region. Of hospitals, 82% had in-house computed tomography and/or magnetic resonance imaging scanners. In the operating room, most neurosurgeons had access to a high-speed drill (91%) but lacked microscopes and endoscopic sets (only 64% and 36% had these tools, respectively). There were no neurointensivists or neurological intensive care units in the entire country, and there was a paucity of neurovascular surgeries and functional neurosurgical procedures., Conclusions: The provision of neurosurgical care in Ghana has come a long way since the 1960s. However, the neurosurgical community continues to face significant challenges. Alleviating these barriers to care will call for systems-level changes that allow for the prioritization of neurosurgical care within the Ghanaian health care system., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Africa bears more than 15% of the global burden of neurosurgical disease; however, it has the lowest neurosurgical workforce density worldwide. The past decade has seen an increase in neurosurgery residency programs on the continent. It is unclear how these residency programs are similar or viable. This study highlights the current status and interdepartmental and regional differences, with the main objective of offering a template for improving the provision of neurosurgical education on the continent., Methods: PubMed and Google Scholar were searched using keywords related to "neurosurgery," "training," and "Africa" from database inception to October 13, 2021. The residency curricula were analyzed using a standardized and validated medical education curriculum viability tool., Results: Curricula from 14 African countries were identified. The curricula differed in resident recruitment, evaluation mode and frequency, curriculum content, and length of training. The length of training varied from 4 to 8 years, with a mean of 6 years. The Eastern African region had the highest number of examinations, with a mean of 8.5. Few curricula had correlates of viability: ensuring that the instructors are competent (64.3%), prioritization of faculty development (64.3%), faculty participation in decision making (64.3%), prioritization of resident support services (50%), creating a conducive environment for quality education (42.9%), and addressing student complaints (28.6%)., Conclusions: There are significant differences in the African postgraduate neurosurgical education curriculum warranting standardization. This study identifies areas of improvement for neurosurgical education in Africa., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Africa has an increased burden of neurosurgical diseases with an estimate of 1,986,392 neurosurgical cases, 108,824 neurosurgical case capacity, and 1,877,568 case deficits yearly. Literature suggests that about 8420 neurosurgeons are needed to fill this vast gap. The main objective of this study is to elucidate barriers encountered in pursuing neurosurgery training in the African context., Methods: A cross-sectional electronic survey, developed in English and subsequently translated into French, was utilized. This was disseminated among medical students, medical interns, and junior doctors in all 5 African regions., Results: A total of 491 responses were received from the following 5 African regions: West Africa (30.5%), East Africa (30.3%), Central Africa (18.1%), North Africa (11.8%), and Southern Africa (9.2%). Of the participants, 55.2% were men and 44.8% were women. Seventy-six percent of respondents were aware of the neurosurgery deficit in Africa. Barriers to pursuing neurosurgery included discouragement from others over lack of an "ideal personality" trait, culture/cultural beliefs as related to gender roles, lack of mentorship, inadequate neurosurgical training opportunities, poor health infrastructure for neurosurgical practice in Africa, poor patient outcomes, and challenges with work/life balance were some of the barriers highlighted to pursuing neurosurgical career on the continent., Conclusion: Even with its robust population growth, Africa is not producing enough neurosurgeons to meet the demands of the population due to several barriers. Delineating these challenges and barriers represents an important step in developing sustainable mechanisms for recruitment, training, mentorship, and support of burgeoning African neurosurgeons., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Preoperative malnutrition is associated with increased postoperative complication rate and hospital length of stay. However, the degree to which these risks can be mitigated by nutritional consultation has not been well described. To address this, we sought to determine if a preoperative nutrition consult was associated with decreased 30-day complication rate and hospital length of stay., Methods: Adult patients who underwent neurosurgical intervention for spinal metastases at a tertiary care institution between 2008 and 2016 were retrospectively reviewed. Stepwise multivariable linear regression analyses were used to identify associations with 30-day complication rate and hospital length of stay., Results: Among 95 patients who met inclusion criteria, the average length of stay was 8.9 days and 40 patients (42.1%) experienced one or more postoperative complications. On multivariable analysis, 30-day complication rates were higher in patients with the absence of a preoperative nutrition consult, a Modified Charlson Comorbidity Index score of greater than 2 points, greater operative blood loss, and malnutrition (Nutritional Risk Index score <97.5). Furthermore, hospitalization duration was increased with the absence of a nutrition consult, malnutrition, congestive heart failure, and prior systemic therapy in the multivariable analysis., Conclusions: On multivariable analysis, receipt of a preoperative nutrition consult was associated with both decreased 30-day complication rate and shorter hospitalization. We therefore posit that greater implementation of nutritional counseling may help to decrease complication rates and expedite discharge in patients undergoing surgical intervention for spinal metastases., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Study Design: Systematic review., Objectives: Sacral chordomas are rare, primary tumors of the spine, best treated with en bloc resection. The purpose of this study was to assess the literature for resected sacral chordoma and to quantify the prevalence of, risk factors for, and treatment outcomes of local and distant recurrence therein., Methods: We searched 5 online databases from January 1980 to May 2016 to find articles that report survival, recurrence outcomes, and/or prognostic factors for the resected sacral chordoma patient population. Characteristics and clinical outcomes of the pooled cohort are reported. Fisher exact tests, unpaired t tests, and one-way analysis of variance were used to investigate patient- and treatment-associated prognostic factors for local and distant recurrence. Survival analyses were performed for time to local recurrence and death. The protocol's PROSPERO ID is CRD42015024384., Results: Fifty-seven studies, with 1235 unique sacral chordoma patients, were included in this review. Local and distant recurrence occurred in 42.6% and 22.4% of patients with adequate follow-up, respectively. Kaplan-Meier overall median survival for patients with and without recurrence were 98 and 209 months after surgery, respectively. Wide surgical margin was associated with a lower rate of local recurrence; and wide surgical margin, female sex, and patient age ≥65 years were associated with lower rates of distant recurrence., Conclusions: While surgical margin remains the most significant prognostic factor for local and distant recurrence, combined surgical approach may be associated with local recurrence. Male sex and age <65 years may be associated with distant recurrence. Patients with risk factors for recurrence should undergo close monitoring to maximize survival., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: C. Rory Goodwin: UNCF Merck Postdoctoral Fellow and has received an award from the Burroughs Wellcome Fund. Daniel Kerekes: None. A. Karim Ahmed: Has received an award from the NREF Medical Student Summer Research Fellowship. Jorrit-Jan Verlaan: None. Chetan Bettegowda: None. Nancy Abu-Bonsrah: None. Daniel M. Sciubba: Consultant for Medtronic, Globus, DePuy, Styrker, and Orthofix.

Background Context: Despite advances in spinal oncology, research in patient-based prognostic calculators for metastatic spine disease is lacking. Much of the literature in this area investigates the general predictive accuracy of scoring systems in heterogeneous populations, with few studies considering the accuracy of scoring systems based on patient specifics such as type of primary tumor., Purpose: The aim of the present study was to compare the ability of widespread scoring systems to estimate both overall survival at various time points and tumor-specific survival for patients undergoing surgical treatment for metastatic spine disease in order to provide surgeons with information to determine the most appropriate scoring system for a specific patient and timeline., Study Design: This is a retrospective study., Patient Sample: Patients who underwent surgical resection for metastatic spine disease at a single institution were included., Outcome Measures: Areas under the receiver operating characteristic curves were generated from comparison of actual survival of patients and survival as predicted by application of prevalent scoring systems., Methods: A preoperative score for all 176 patients was retrospectively calculated utilizing the Skeletal Oncology Research Group (SORG) Classic Scoring Algorithm, SORG Nomogram, original Tokuhashi, revised Tokuhashi, Tomita, original Bauer, modified Bauer, Katagiri, and van der Linden scoring systems. Univariate and multivariate Cox proportional hazard models were constructed to assess the association of patient variables with survival. Receiver operating characteristic analysis modeling was utilized to quantify the accuracy of each test at different end points and for different primary tumor subgroups. No funds were received in support of this work. The authors have no conflicts of interest to disclose., Results: Among all patients surgically treated for metastatic spine disease, the SORG Nomogram demonstrated the highest accuracy at predicting 30-day (area under the curve [AUC] 0.81) and 90-day (AUC 0.70) survival after surgery. The original Tokuhashi was the most accurate at predicting 365-day survival (AUC 0.78). Multivariate analysis demonstrated multiple preoperative factors strongly associated with survival after surgery for spinal metastasis. The accuracy of each scoring system in determining survival probability relative to primary tumor etiology and time elapsed since surgery was assessed., Conclusions: Among the nine scoring systems assessed, the present study determined the most accurate scoring system for short-term (30-day), intermediate (90-day), and long-term (365-day) survival, relative to primary tumor etiology. The findings of the present study may be utilized by surgeons in a personalized effort to select the most appropriate scoring system for a given patient., (Copyright © 2018. Published by Elsevier Inc.)

Study Design: Systematic review., Objectives: The objective of this systematic review was to answer 2 key questions: (1) What is the clinical presentation and probability of symptomatic improvement following treatment for patients with renal cell carcinoma (RCC) of the spine? (2) What is the overall survival of patients diagnosed with spinal metastases from RCC?, Methods: A literature review was performed to identify articles that reported on survival, clinical outcomes, and/or prognostic factors in the RCC population with spinal metastases from 1986 to 2016., Results: Forty-eight articles (807 patients) were included. The Fuhrman Nuclear Grade has been significantly associated with survival in previous studies but was underpowered in the current study. The Memorial Sloan-Kettering Cancer Center Score (MSKCC/Motzer) was also underpowered in the current study. From the time of spinal metastasis, the mean and median survival for patients with previously diagnosed primary RCC was 8.75 and 11.7 months, respectively, whereas synchronously diagnosed patients (primary RCC and spinal metastasis) had a mean and median survival of 6.75 and 11 months, respectively. Patients with a "low" (0-8), "intermediate" (9-11), or "high" (12-15) revised Tokuhashi score at initial presentation had a median survival of 5.4, 11.7, and 32.9 months, respectively., Conclusion: Patients with either a synchronous or latent diagnosis of RCC survived greater than 6 months from the time of presentation. Initial Furhman grade, Tokuhashi score, and MSKCC/Motzer can be useful tools in informing patient-specific prognosis for those with metastatic RCC of the spine., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: C. Rory Goodwin: UNCF Merck Postdoctoral Fellow and has received an award from the Burroughs Wellcome Fund and the Johns Hopkins Neurosurgery Pain Research Institute. A. Karim Ahmed: has received an award from the NREF Medical Student Summer Research Fellowship. Ilya Laufer: Globus, SpineWave, Depuy/Synthes, Medtronic, BrainLab. Charles G. Fisher: Royalties from Medtronic, consulting for Medtronic and Nuvasive, and research support from OREF, AOSpine, and Medtronic. Daniel M. Sciubba: consultant for Medtronic, Globus, DePuy, and Stryker. The remaining authors have no conflicts of interest to disclose.

OBJECTIVE Resection of metastatic spine tumors can improve patients' quality of life by addressing pain or neurological compromise. However, resections are often complicated by wound dehiscence, infection, instrumentation failures, and the need for reoperation. Moreover, when reoperations are needed, the most common indication is surgical site infection and wound breakdown. In turn, wound reoperations increase morbidity as well as the length and cost of hospitalization. The aim of this study was to examine perioperative risk factors associated with increased rate of wound reoperations after metastatic spine tumor resection. METHODS A retrospective study of patients at a single institution who underwent metastatic spine tumor resection between 2003 and 2013 was conducted. Factors with a p value < 0.200 in a univariate analysis were included in the multivariate model. RESULTS A total of 159 patients were included in this study. Karnofsky Performance Scale score > 70, smoking status, hypertension, thromboembolic events, hyperlipidemia, increasing number of vertebral levels, and posterior approach were included in the multivariate analysis. Thromboembolic events (95% CI 1.19-48.5, p = 0.032) and number of levels involved were independently associated with increased wound reoperation rates in the multivariate model. For each additional spinal level involved, the risk for wound reoperations increased by 21% (95% CI 1.03-1.43, p = 0.018). CONCLUSIONS Although wound complications and subsequent reoperations are potential risks for all patients with metastatic spine tumor, due to adjuvant radiotherapy and other medical comorbidities, this study identified patients with thromboembolic events or those requiring a larger incision as being at the highest risk. Measures intended to decrease the occurrence of perioperative venous thromboembolism and to improve wound care, especially for long incisions, may decrease wound-related revision surgeries in this vulnerable group of patients.

Objective: To compare in-hospital complication rates in pediatric patients with atlantoaxial and subaxial injuries undergoing either external fixation or surgical fusion., Patients and Methods: Baseline and outcome data were obtained from the 2002-2011 Nationwide Inpatient Sample (NIS) for patients under the age of 18 with a diagnosis of cervical spine fracture without spinal cord injury or cervical spine subluxation. Patients who underwent external immobilization or internal fixation were included for analysis. Variables analyzed included length of stay, in-hospital mortality, discharge disposition, total hospital charges, and development of at least one in-hospital complication., Results: A total of 2878 pediatric patients with cervical spine injury were identified; 1462 patients (50.8%) with atlantoaxial (C1-2) injury and 1416 (49.2%) with subaxial (C3-7) injury. Among atlantoaxial injury patients, external fixation was associated with lower total charges ($73,786 vs. $98,158, p = .040) and a lower likelihood of developing at least one complication (1.9% vs. 6.8%, p = .029) compared to surgical fusion, and was a more common treatment for subluxation alone (16.4% vs. 2.6%, p < .001). Among subaxial injury patients, there were no significant differences in age (p = .262), length of stay (p = .196), occurrence of at least one complication (p = .334), or total charges (p = .142). Subaxial subluxation injuries alone were treated more often with surgical fusion (2.2% vs. 1.2%, p < .001)., Conclusion: Optimal treatment of patients with cervical injury may vary by location of injury. Our findings warrant further investigation into the difference in clinical outcomes between surgical and non-surgical management of atlantoaxial and subaxial injury., (Copyright © 2018. Published by Elsevier B.V.)

Study Design: Retrospective case-control study., Objectives: To identify incidence and risk factors for percutaneous endoscopic gastrostomy (PEG) tube placement after anterior cervical fusion (ACF)., Methods: Adult patients undergoing elective ACF with/without corpectomy for spondylosis from 2002 to 2011 were identified using the Nationwide Inpatient Sample database. The primary outcome measure was PEG tube placement; secondary outcomes included in-hospital mortality, total hospital charges, and discharge disposition. Multiple regression analyses were conducted to identify independent predictors of PEG tube placement., Results: Of 164 097 patients, 217 (0.13%) required a PEG tube. Patients needing PEG tube placement were older (69 vs 52 years; P < .001) and more likely to be male (65% vs 46.6%; P < .001) when compared with control patients. After regression analysis, age over 65 year (odds ratio [OR] = 4.16; P < .001) was the strongest independent predictor for PEG tube placement; other associated factors included male gender (OR = 2.14; P < .001), congestive heart failure (OR = 4.11; P < .001), anemia (OR = 3.52; P < .001), alcohol abuse (OR = 2.80; P = .009), renal failure (OR = 2.25; P = .003), chronic lung disease (OR = 1.78; P < .001), corpectomy (OR = 2.16; P < .001), and fusion of ≥3 segments (OR = 1.74; P < .001). Mortality rate for patients requiring PEG tube placement was 5.1% versus 0.05% for controls ( P < .001); average hospital charges were $134 379 versus $39 519 ( P < .001), and nonroutine discharges were seen in 89.3% versus only 6.4% for controls ( P < .001)., Conclusions: The incidence of PEG tube placement after ACF was 0.13% in this study. Identified risk factors included age >65, corpectomy, fusion of ≥3 segments, and various comorbidities. Additionally, there may be increased risk of in-hospital mortality, hospital charges, and nonroutine discharges among these patients., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Daniel M. Sciubba, MD: Consultant for Medtronic, Stryker, Depuy Synthes, Globus, and Orthofix.

Objective: Frailty, decreased physiologic reserve and increased vulnerability to stressors beyond what is expected for normal aging, is associated with increased risk of morbidity and mortality. The objective of this study was to develop a preoperative frailty index for patients undergoing surgery for primary spinal column tumors that predicts morbidity, mortality, and length of stay., Methods: The Nationwide Inpatient Sample database from 2002 to 2011 was used to identify patients who underwent surgery for a primary spinal tumor. The spinal tumor frailty index, consisting of 9 items, was applied to each patient. Patients were characterized as "not frail" (0), "mildly frail" (1), "moderately frail" (2), and "severely frail" (≥3)., Results: Inclusion criteria were met by 1589 patients. Overall major complication rate was 10.6%. Compared with patients without frailty, patients with mild (odds ratio 3.83; 95% confidence interval, 2.63-5.58), moderate (odds ratio 6.80; 95% confidence interval, 4.10-11.3), and severe frailty (odds ratio 13.05; 95% confidence interval, 6.34-26.87) had significantly increased odds of developing complications (all P < 0.001). Mean length of stay was 6.4 days ± 0.2, 9.8 days ± 0.6, 14.4 days ± 1.7, and 18.3 days ± 2.6 for patients without frailty, with mild frailty, with moderate frailty, and with severe frailty (P < 0.05 between all groups)., Conclusions: Compared with patients without frailty, patients with mild, moderate, and severe frailty had significantly increased odds of developing postoperative complications. Systematic evaluation of preoperative frailty should play a key role in decision making for patients undergoing surgery for primary spinal tumors., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Extramammary Paget disease is an intraepithelial neoplasm affecting cells rich in apocrine glands-often located in the vulvar, scrotal, or perianal region. It typically affects older patients, between the ages of 50 and 80years old, and is most often limited to the epidermis. A 47-year-old Asian male first presented with enlargement of the right inguinal lymph node. A subsequent biopsy revealed extrammamary Paget disease of the scrotum. The patient eventually developed significant worsening back pain with bilateral lower extremity numbness and weakness three months later. Imaging demonstrated a pathologic compression fracture of the L4 vertebral body with metastatic epidural spinal cord compression. The patient underwent surgical decompression of the spine with bilateral L4 laminectomy, resection of epidural tumor, and pedicle screw fixation from L2 to S1. Surgical pathology demonstrated metastatic adenocarcinoma consistent with extramammary Paget disease. Although two other case reports have described spinal metastases from extramammary Paget disease, to the author's knowledge, this represents the first report of surgical decompression and fusion for extramammary Paget disease of the spine., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: The spine is the most common site of skeletal metastases, affecting approximately 30% of individuals with cancer. The aim of surgical treatment for metastatic spine disease is generally palliative to address pain and/or neurologic compromise, significantly improving patients' quality of life. Patients with metastatic spine disease, however, represent a vulnerable cohort and may have comorbidities or previous treatments that impair the structural integrity of spinal hardware. As such, identifying factors that may contribute to hardware failure is an essential component in treating individuals with metastatic spine disease., Objective: The aim of this study was to identify pre-operative risk factors associated with hardware failure in patients undergoing surgical treatment for metastatic spine disease., Methods: A retrospective cohort study was conducted to include patients surgically treated for metastatic spine tumors between 2003 and 2013, at a single institution. A univariate analysis was initially performed to identify associated factors. Any associated factor with a p-value <0.20 was included in the multivariate analysis., Results: 3 patients (1.9%), of the 159 patients included in the study, had failure of the spine instrumentation. 1 patient had metastatic prostate cancer, and 2 had metastatic breast cancer. Patient demographics, co-morbidities, tumor location, and primary tumor etiology were not found to be statistically significant, with respect to hardware failure. Predictive factors included in the multivariate model were other bone metastasis, visceral metastasis, brain metastasis, Modified Rankin scale, previous systemic chemotherapy, previous radiation to the spine, and mean survival. Previous radiation to the spine was the only factor to be significantly associated (p=0.029), present in all three patients with hardware failure. Of note, there was a trend indicating that patients with longer life expectancies were more likely to experience hardware failure (mean survival of 16.7months in non-failure cohort vs. 33months in failure cohort), though this did not achieve statistical significance due to the limited sample size of patients with hardware failure., Conclusion: Hardware failure is a risk for all patients who undergo instrumentation following resection for metastatic spine tumors. This study identified that pre-operative radiation may increase the risk for hardware failure in this population., (Copyright © 2017 Elsevier Ltd. All rights reserved.)