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There is minimal information on COVID-19 pandemic’s national impact on pediatric neurosurgical operative volumes. In this study, using a national database, TriNetX, we compared the overall and seasonal trends of pediatric neurosurgical procedure volumes in the United States during the pandemic to pre-pandemic periods. In the United States, the incidence of COVID-19 began to rise in September 2020 and reached its maximum peak between December 2020 and January 2021. During this time, there was an inverse relationship between pediatric neurosurgical operative volumes and the incidence of COVID-19 cases. From March 2020 to May 2021, there was a significant decrease in the number of pediatric shunt (-11.7% mean change, p = 0.006), epilepsy (-16.6%, p < 0.001), and neurosurgical trauma (-13.8%, p < 0.001) surgeries compared to pre-pandemic years. The seasonal analysis also yielded a broad decrease in most subcategories in spring 2020 with significant decreases in pediatric spine, epilepsy, and trauma cases. To the best of our knowledge, this is the first study to report a national decline in pediatric shunt, epilepsy, and neurosurgical trauma operative volumes during the pandemic. This could be due to fear-related changes in health-seeking behavior as well as underdiagnosis during the COVID-19 pandemic.

Retrospective analysis of a prospectively maintained database.To evaluate the effects of interhospital transfer (IHT) status, age, and frailty on postoperative outcomes in patients who underwent spine surgery.The National Surgical Quality Improvement Program (NSQIP) database was queried for patients who underwent spine surgeries from 2015 to 2019 (N = 295,875). Univariate and multivariable analyses were utilized to analyze the effect of IHT on postoperative outcomes and the contribution of baseline frailty status (mFI-5 score stratified into "pre-frail", "frail", and "severely frail") on outcomes in IHT patients. Effect sizes were summarized by odds ratio (OR) with associated 95% confidence intervals (95% CI).Of 295,875 patients in the study, 3.3% (N = 9666) were IHT status. On multivariable analysis, controlling for covariates, IHT status was significantly associated with greater likelihood of 30-day mortality (odds ratio [OR] = 9.3), major complications (OR=5.0), Clavien-Dindo (CD) grade IV complications (OR=7.0), unplanned readmission (OR=2.1), unplanned reoperation (OR=2.6), eLOS (OR=16.1), and discharge to non-home destination (OR=12.7) (all P 0.001). Increasing frailty was significantly associated with poor outcomes in spine surgery patients with IHT status compared to chronological age.This study provides evidence that IHT status is associated with poor outcomes in spine surgery patients. Furthermore, increasing frailty more than increasing age was a robust predictor of poor outcomes among IHT spine surgical patients. Baseline frailty status, as measured by the mFI-5, may be utilized for preoperative risk stratification of patients with IHT status with anticipated spine surgery.

In long thoracolumbar deformity surgery, accurate screw positioning is critical for spinal stability. We assessed pedicle and pelvic screw accuracy and radiation exposure in patients undergoing long thoracolumbar deformity fusion surgery (≥4 levels) involving 3-dimensional fluoroscopy (O-Arm/Stealth) navigation.In this retrospective single-center cohort study, all patients aged18 years who underwent fusion in 2016-2018 were reviewed. O-Arm images were assessed for screw accuracy. Effective radiation doses were calculated. The primary outcome was pedicle screw accuracy (Heary grade). Secondary outcomes were pelvic fixation screw accuracy, radiation exposure, and screw-related peri- and postoperative complications or revision surgery within three years.Of 1,477 pedicle screws placed in 91 patients (mean 16.41±5.6 screws/patient), 1,208 pedicle screws (81.8%) could be evaluated by 3D imaging after placement. Heary Grade I placement was achieved in 1,150 screws (95.2%), Grade II in 47 (3.9%), Grade III in 10 (0.82%), Grade IV in 1 (0.08%), and Grade V in 0; Grade III-V were replaced intraoperatively. One of 60 (1.6%) sacroiliac screws placed showed medial cortical breach and was replaced. The average O-Arm-related effective dose was 29.54±14.29 mSv and effective dose/spin was 8.25±2.65 mSv. No postoperative neurological worsening, vascular injuries, or revision surgeries for screw misplacement were recorded.With effective radiation doses similar to those in interventional neuroendovascular procedures, the use of O-Arm in multilevel complex deformity surgery resulted in high screw accuracy, no need for surgical revision because of screw malposition, less additional imaging, and no radiation exposure for the surgical team.

Esthesioneuroblastoma (ENB) is a rare sinonasal malignant neoplasm with 40% 5-year survival. Because of the rarity of the tumor, the optimal treatment and subsequent prediction of prognosis are unclear. We studied a modern series of patients with ENB to evaluate the association of immunohistochemical (IHC) markers and clinical stages/grades with outcomes.A single-center retrospective review of patients with ENB treated during a 25-year period was performed. A systematic literature review evaluating the prognostic benefits of current staging systems in evaluating survival outcomes in ENB was undertaken.Among 29 included patients, 25 (85%) were treated surgically at our institution, with 76% of those endoscopically resected; 7 (24.1%) received chemotherapy, and 18 (62.1%) received radiation therapy. The 5-year overall survival (OS) was 91.3%, and 10-year OS was 78.3%. Progression-free survival (PFS) at 5 and 10 years was 85.6% and 68.2%, respectively. A total of 36 distinct IHC markers were used to diagnose ENB but were inconsistent in predicting survival. A systematic literature review revealed predictive accuracy for OS using the Kadish, TNM, and Hyams staging/grading systems was 68%, 42%, and 50%, respectively.This study reports the 5- and 10-year OS and PFS in a modern series of patients with ENB. No traditional IHC marker consistently predicted outcome. Some novel reviewed markers show promise but have yet to enter clinical mainstream use. Our systematic review of accepted staging/grading systems also demonstrated a need for further investigation due to limited prognostic accuracy.

With limited healthcare resources and risks associated with unwarranted interhospital transfers (IHT), it is important to select patients most likely to have improved outcomes with IHT. The present study analyzed the effect of IHT and frailty on postoperative outcomes in a large database of patients who underwent cranial neurosurgical operations.The National Surgical Quality Improvement Program (NSQIP) database was queried for patients who underwent cranial neurosurgical procedures (2015-2019, N = 47,736). Baseline demographics, clinical characteristics, and outcome variables were compared between IHT and n-IHT patients. Univariate and multivariable analyses analyzed the effect of IHT status on postoperative outcomes and the utility of frailty (modified frailty index-5 [mFI-5] stratified into "pre-frail, "frail", and "severely frail") as a preoperative risk factor. Effect sizes from regression analyses were presented as odds ratio (OR) with associated 95% confidence intervals (95% CI).Of 47,736 patients with cranial neurosurgical operations, 9612 (20.1%) were IHT. Patients with IHT were older, frailer, with a higher rate of functional dependence. In multivariable analysis adjusted for baseline covariates, IHT status was independent associated with 30-day mortality (OR: 2.0, 95% CI: 1.2-3.6), major complication (OR: 1.5, 95% CI: 1.1-2.1), extended hospital length of stay (eLOS) (OR: 3.8, 95% CI: 3.6-4.1), and non-routine discharge disposition (OR: 2.4, 95% CI: 1.8-3.2) (all p 0.05). Within the IHT cohort, increasing frailty ("pre-frail", "frail", "severely frail") was independently associated with increasing odds of 30-day mortality (OR: 1.4, 1.9, 3.9), major complication (OR: 1.4, 1.9, 3.3), unplanned readmission (OR: 1.1, 1.4, 2.1), reoperation (OR: 1.3, 1.5, 1.9), eLOS (OR: 1.2, 1.3, 1.5), and non-routine discharge (OR: 1.4, 1.9, 4.4) (all p 0.05). All levels of frailty were more strongly associated with postoperative outcomes than chronological age.This novel analysis suggests that patients transferred for cranial neurosurgery operations are significantly more likely to have worse postoperative health outcomes. Furthermore, the analysis suggests that frailty (as measured by mFI-5) is a powerful independent predictor of outcomes in transferred cranial neurosurgery patients. The findings support the use of frailty scoring in the pre-transfer and preoperative setting for patient counseling and risk stratification.

Traumatic brain injury is a significant public health concern often complicated by hospital-acquired infections (HAIs); however, previous evaluations of factors predictive of risk for HAI have generally been single-center analyses or limited to surgical site infections. Frailty assessment has been shown to provide effective risk stratification in neurosurgery. We evaluated whether frailty status or age is more predictive of HAIs and length of stay among neurotrauma patients requiring craniectomy/craniotomy.In this cross-sectional analysis, the American College of Surgeons National Surgical Quality Improvement Program 2015-2019 dataset was queried to identify neurotrauma patients who underwent craniectomies/craniotomies. The effects of frailty status (using the 5-factor modified frailty index [mFI-5]) and age on occurrence of HAIs and other 30-day adverse events were compared using univariate analysis. The discriminative ability of each measure was defined by multivariate modeling.Of 3284 patients identified, 1172 (35.7%) contracted an HAI postoperatively. Increasing frailty score predicted increased HAI risk (odds ratio [OR] = 1.36, 95% confidence interval [CI] = 1.05-1.77, P = 0.022 for mFI-5 = 1 and OR = 2.01, 95% CI = 1.30-3.11, P = 0.002 for mFI-5≥3), whereas increasing age did not (OR = 0.996, 95% CI = 0.989-1.002, P = 0.009). Median length of stay was significantly longer in patients with HAI (16 days [IQR = 9-23]) versus no HAI (7 days [IQR = 4-13]) (P0.001). Median daily costs on the ward and neuro-intensive care unit were higher with HAI than with no HAI (neuro-ICU: $111,818.08 [IQR = 46,418.05-189,947.34] vs. $48,920.41 [IQR = 20,185.20-107,712.54], P0.001).Increasing mFI-5 correlated with increased HAI risk. Neurotrauma patients who developed an HAI after craniectomy/craniotomy had longer hospitalizations and higher care costs. Frailty scoring improves risk stratification among these patients and may assist in reducing total hospital length of stay and total accrued costs to patients.

Multinodular and vacuolating neuronal tumor (MVNT) is a rare benign brain lesion, commonly found in middle-aged adults. The patients experience a range of symptoms from being asymptomatic to epileptic seizures, with headache being the most common symptom. Here we report a case of an incidental diagnosis of MVNT in a young female. A 25-year-old female with a past medical history of occasional headaches without seizures or any focal neurological deficit presented after a motor vehicle rollover. The MRI brain revealed an incidental finding of a subcortical lesion in the right parietal lobe with T2-FLAIR (fluid-attenuated inversion recovery) hyperintensity between the cystic portions, indicative of a possible MVNT, with a less probable chance of dysembryoplastic neuroepithelial tumor based on the subcortical location of the lesion. No neurosurgical intervention was recommended. With one-year follow-up, no changes were noted on neuroimaging, and the patient remained stable without any neurological symptoms. The MVNT is a rare brain lesion that presents with benign features. In patients with epileptic symptoms, surgical resection of the lesion can be curative. However, in asymptomatic patients, careful monitoring may be sufficient, as described in this case.

Increasing patient age has been associated with worse outcomes after pituitary adenoma resection in previous studies, but the prognostic value of frailty compared with advancing age on pituitary adenoma resection outcomes has not been clearly evaluated.The National Surgical Quality Improvement Program from 2015 to 2019 was queried for data for patients aged18 years who underwent pituitary adenoma resection (n = 1454 identified patients). Univariate and multivariate analyses of age and frailty (5-factor modified frailty index [mFI-5]) were performed on 30-day mortality, major complications, extended length of stay (eLOS), discharge destination, and readmission and reoperation. The receiver operating characteristic curve analysis was performed to compare effect of age and mFI-5.On univariate analysis, increasing frailty was significantly associated with greater risk of unplanned readmission (frail: odds ratio [OR], 1.9; 95% confidence interval [CI], 1.2-3.2; severely frail: OR, 6.9; 95% CI, 2.4-19.8) and a major complication (frail: OR, 3.6; 95% CI, 2.1-6.1). Severe frailty was also associated with nonhome discharge (OR, 10.6; 95% CI, 3.2-35.8) and eLOS (OR, 4.5; 95% CI, 1.5-13.4). Increasing age was not associated with any of these outcome measures. Multivariate analysis also demonstrated similar trends. In receiver operating characteristic curve analysis, the mFI-5 score showed higher discrimination for major complications compared with age (area under the curve: 0.624 vs. 0.503; P0.001).Increasing frailty, and not advancing age, was an independent predictor for major complications, unplanned readmissions, eLOS, and nonhome discharge after pituitary adenoma resection, suggesting frailty to be superior to age in preoperative risk stratification in this patient population.

Bell’s palsy is a relatively rare neurologic disorder with a limited selection of helpful therapies. This case report describes the author’s initial three-month experience living with severe Bell’s palsy, including a detailed history and timeline of the initial development of symptoms, treatments pursued, and psychological stress during the disease progression. A particular focus is placed on the emotional burden Bell’s palsy can have, exploring possible avenues to improve physician to patient education on mental health and well-being during initial and delayed recovery.

Although pleomorphic xanthoastrocytomas generally carry a fair prognosis, anaplastic transformation has been identified in a subset of cases.We present the case of a patient with primary anaplastic pleomorphic xanthoastrocytoma (APXA) that demonstrated rapid recurrence and diffuse leptomeningeal spread of disease three months postoperatively, causing severe visual impairment and acute ischemic strokes leading to death.We believe this is the fastest reported time to leptomeningeal dissemination and death from the initial diagnosis. Through this case, we show how anaplastic features can have a highly variable biological effect on disease progression. We believe earlier craniospinal imaging at the time of APXA diagnosis should be pursued to manage disease progression more aggressively with currently recommended adjuvant therapies.

Background: The awake craniotomy (AC) procedure allows for safe and maximal resection of brain tumors from highly eloquent regions. However, geriatric patients are often viewed as poor candidates for AC due to age and medical comorbidities. Frailty assessments gauge physiological reserve for surgery and are valuable tools for preoperative decision-making. Here, we present a novel case illustrating how frailty scoring enabled an elderly but otherwise healthy female to undergo successful AC for tumor resection. Case Description: A 92-year-old right-handed female with history of hypertension and basal cell skin cancer presented with a 1-month history of progressive aphasia and was found to have a ring-enhancing left frontoparietal mass abutting the rolandic cortex concerning for malignant neoplasm. Frailty scoring with the recalibrated risk analysis index (RAI-C) tool revealed a score of 30 (of 81) indicating low surgical risk. The patient and family were counseled appropriately that, despite advanced chronological age, a low frailty score predicts favorable surgical outcomes. The patient underwent left-sided AC for resection of tumor and experienced immediate improvement of speech intraoperatively. After surgery, the patient was neurologically intact and had an unremarkable postoperative course with significant improvements from preoperatively baseline at follow-up. Conclusion: To the best of our knowledge, this case represents the oldest patient to undergo successful AC for brain tumor resection. Nonfrail patients over 90 years of age with the proper indications may tolerate cranial surgery. Frailty scoring is a powerful tool for preoperative risk assessment in the geriatric neurosurgery population.

Neurosurgery residents spend a significant amount of their time teaching patients, families, students, residents, and other health professionals. To help ensure competence in their residents’ teaching abilities, many specialties have established formal residents-as-teachers (RAT) curricula; however, such formalized curricula are often lacking in neurosurgery programs. The authors’ goal was to develop and implement a formal RAT curriculum, designed with neurosurgery residents’ other responsibilities in mind, to improve residents’ formal and informal teaching abilities. Here, the authors report on the design of a formalized teaching curriculum tailored for the needs of neurosurgical residents, with a focus on deliberate practice and minimal time needed for preparation. The curriculum, designed using Kern’s 6 steps of curriculum design as a framework, comprises 5 lecture series spread over 3 years, repeated twice through a resident’s training, with each lecture series outlined with its respective topics and objectives. Opportunities for observed teaching as well as informal and formal evaluation will be provided to residents. The program will be evaluated on a yearly basis using direct and anonymized resident feedback on the RAT curriculum. Measures of program success will also include pre- and postprogram medical student and peer evaluation of residents. These data will be used for continual improvement of the curriculum as it is implemented. Successes and shortcomings of this program will be disseminated by publication, presentations, and placement on the authors’ department website and social media. This paper may serve as a foundation for other neurosurgical programs to develop RAT curricula for greater enhancement of resident teaching abilities.

A surge in interest in cortical bone trajectory (CBT), first described by Santoni in 2009, may be a result of its numerous advantages, including reduced surgical incision length and lateral dissection, limited disruption of the facet joints, and decreased blood loss. In addition, CBT offers improved screw pullout strength and the ability to perform hybrid constructs with pedicle screws using minimally invasive approaches. However, one of the main limitations of the technique involves the small screw size, which limits the potential for long-segment constructs. We describe a technique involving a more in-line anatomical trajectory, allowing for larger screw diameters. A feasibility study using a cadaveric model was performed and evaluated. Moreover, a focused review of the literature on the use of CBT was performed. Screw entry points are located along the inferomedial aspect of the facet and angled superolaterally. The use of this technique allows for the placement of larger screws (4.5 to 6.5 mm diameter) without pedicle breaches along with the alignment of screw heads from L1 to S1. In addition, the technique can be performed using stereotactic navigation or fluoroscopy. A direct, more in-line technique allows for larger screws to be placed using CBT. This technique can be combined with minimally invasive approaches. The potential advantages of the CBT technique support its use as a probable alternative to traditional pedicle screw fixation techniques.