Vascular

Neurosurgical Education for Medical Students: A Scoping Review

Neurosurgeons have a rich history of involvement in medical student education. We review the scope of related published works with the goal of highlighting recently increased efforts to innovate in neurosurgical education and discuss where future efforts must go. A scoping review was performed after comprehensive search of PubMed MEDLINE and Embase databases. Among the 2314 articles returned in the search, 54 were selected for inclusion and review. Articles are discussed in the context of neurosurgery electives, American Association of Neurological Surgeons chapters and medical school programs, national neurosurgery courses, neurosurgery education materials, neurosurgery career perceptions, and the impact of coronavirus disease 2019. Despite increasing need for neurosurgical education in medical school, available experiences in formal curricula are diminishing. Longitudinal exposure to neurosurgery throughout medical school will help ensure a foundational understanding of neurosurgical disease management for all physicians and provide a pathway of exploration, education, and mentorship for the most suitable candidates. Neurosurgery faculty mentorship is particularly important to ensure that the next generation of neurologic surgeons is well equipped to treat patients, catalyze innovative research, and espouse both diverse perspectives and novel ideas.

Conscious sedation compared to general anesthesia for intracranial mechanical thrombectomy: A meta-analysis

INTRODUCTION

Endovascular therapy is the standard of care for severe acute ischemic stroke caused by large-vessel occlusion in the anterior circulation, but there is a debate on the optimal anesthetic approach during this therapy. Meta-analyses of observational studies suggest that general anesthesia increases disability and death compared with conscious sedation However, their results are conflicting. This meta-analysis study was performed to assess the relationship between the effects of general anesthesia compared to conscious sedation during endovascular therapy for acute ischemic stroke.

METHODS

Through a systematic literature search up to August 2020, 18 studies included 4,802 subjects at baseline with endovascular therapy for acute ischemic stroke and reported a total of 1,711 subjects using general anesthesia and 1,961 subjects using conscious sedation were found. They recorded relationships between the effects of general anesthesia compared to conscious sedation during endovascular therapy for acute ischemic stroke. Odds ratio (OR) or Mean differences (MD) with 95% confidence intervals (CIs) were calculated between the effect of general anesthesia compared to conscious sedation during endovascular therapy for acute ischemic stroke using the dichotomous or contentious methods with a random or fixed-effect model.

RESULTS

No significant difference were found between general anesthesia and conscious sedation during the endovascular therapy for acute ischemic stroke in functional independence at 90 days (OR, 0.78; 95% CI, 0.44-1.40, p = 40); successful recanalization at 24 hr (OR, 1.23; 95% CI, 0.62-2.41, p = 55); mortality at 90 days (OR, 1.36; 95% CI, 0.83-2.24, p = .22); interventional complication (OR, 1.24; 95% CI, 0.76-2.02, p = .40); symptomatic intracranial hemorrhage (OR, 0.64; 95% CI, 0.41-0.99, p = .05); aspiration pneumonia (OR, 0.96; 95% CI, 0.58-1.58, p = .87); and National Institute of Health Stroke Scale score after 24 hr (MD, 0.38; 95% CI, -1.15-1.91, p = .62); with relative relationship favoring general anesthesia only in decreasing the symptomatic intracranial hemorrhage.

CONCLUSIONS

General anesthesia has no independent relationship compared to conscious sedation during the endovascular therapy for acute ischemic stroke with a relative relationship favoring general anesthesia only in decreasing the symptomatic intracranial hemorrhage. This relationship encouraged us to recommend either anesthetic strategy during the endovascular therapy for acute ischemic stroke with no possible fear of higher complication.

Retrospective radiographic analysis of anterior lumbar fusion for high grade lumbar spondylolisthesis

BACKGROUND

High-grade spondylolisthesis (>50% slippage) is infrequently encountered in adults and frequently requires surgical treatment. The optimal surgical treatment is controversial with limited literature guidance as to optimal approach to treatment. An observational study to examine the technique and radiographic outcomes of adult patients treated with anterior lumbar interbody fusion (ALIF) and posterior percutaneous instrumentation for high-grade spondylolisthesis.

METHODS

ALIF was performed in 5 consecutive patients (3/5 female, 2/5 male) aged 29-67 years old who presented with low back pain and L5 radiculopathy. All patients failed conservative treatment and were treated with L4-5 and L5-S1 ALIF followed by posterior percutaneous L4-S1 pedicle screw and rod fixation. Pre- and postoperative clinical data was collected including L5-S1 posterior disk height in millimeters, millimeters of spondylolisthesis at L5-S1, degrees of segmental lordosis (L4-S1), lumbar lordosis (L1-S1), and lumbar lordosis pelvic incidence (LL-PI) mismatch.

RESULTS

Six weeks following surgery, no patient reported residual L5 radicular symptoms. At last follow up, patient satisfaction, according to Modified Macnab Criteria, was excellent in 4/5 patients and good in 1/5 patient. In the 4 patients with greater than 1 year radiographic follow up, fusion rate was 100% on computed tomography (CT). Mean increase in posterior disk height was 12.5 mm (range, 11.4-13.5 mm). Mean reduction in spondylolisthesis was 58.7% (range, 20.2-100%). Mean segmental (L4-S1) and overall (L1-S1) lumbar lordosis increased by 23.6% (range, 6.5-41.7%) and 16.6% (2.5-31.5%), respectively. Following surgery, LL-PI mismatch decreased from a mean of 16.4 to 10.2 degrees.

CONCLUSIONS

ALIF with posterior percutaneous instrumentation is a safe and effective treatment for high-grade lumbosacral spondylolisthesis in properly selected adults. This technique improves lumbar sagittal parameters and reduces spondylolisthesis. The indirect neural decompression from simultaneous disk height restoration and spondylolisthesis reduction may be associated with lower neurological injury rate compared to posterior-only. Future prospective study is needed to validate this hypothesis.