Neurosurgery

Hubly Surgical

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Hubly Surgical

https://hublysurgical.com/

The manual twist drill used for intracranial access represents an opportunity for potential improvement in efficiency, safety, and ease of use. A new generation of portable electrical drills with smart autostop mechanisms, such as the Hubly cranial drill (Hubly Surgical; Lisle, IL), aim to address these opportunities for improvement.

Two patients received EVDs using the portable electrical autostop drill (PEAD): A 54-year-old woman who suffered a postoperative hemorrhage and a 59-year-old woman who presented with early hydrocephalus secondary to hypertensive subarachnoid hemorrhage (SAH). Between both patients, a total of 9 and 2 access attempts were necessary to breach the inner table and visual dura. Access times in both cases, from skin incision to dural puncture, were less than 5 min. There were no apparent complications with the use of the PEAD in either case, and there was excellent placement of the EVD at the foramen of Monroe in both cases.

Oak et al. demonstrate the first successful use of a portable electrical drill with smart autostop in humans. The PEAD has potential to reduce procedure time and human error. Further development of the smart autostop drill may allow for more consistent and safer EVD placement 1).

A cadaveric study was conducted using both drills to perform several burr holes in the fronto-temporo-parietal region of the skull. An evaluation was performed on the number of dura plunges, and complete burr hole success rates were compared.

A total of 174 craniotomies using the HD and 36 burr holes using the ST perforator were performed. Despite significantly exceeding intended drill bit tolerance by multiple uses of a single-use disposable HD, autostop engaged in 100% of the 174 craniotomies and before violating dura in 99.4% of the 174 craniotomies, with the single dura penetration occurring on craniotomy no. 128 after the single-use drill bit had significantly dulled beyond its single-use tolerance. Autostop engaged before dura penetration for 100% of the 36 burr holes drilled with the ST perforator ( P = .610). All the perforations were complete using the HD after resuming drilling. An autostop mechanism in a cranial drill is not commonly available for portable bedside perforators. In the operating room, most use a mechanical method to stop the rotation after losing bone resistance. This new drill uses an electrical mechanism (smart autostop) to stop drilling, making it a single-use cranial drill with advanced features for safety and efficiency at the bedside.

There was no difference in the safety and efficacy of the new cordless electric drill with smart autostop when performing craniotomies compared with a traditional well-established electric cranial perforator with mechanical autostop on a cadaveric model 2)

1)

Oak A, Dardick J, Rusheen A, Materi J, Weingart J, Gonzalez LF, Anderson WS, Mukherjee D. First-in-human experience of a portable electrical drill with smart autostop for bedside external ventricular drain placement. J Clin Neurosci. 2024 Nov 27;131:110941. doi: 10.1016/j.jocn.2024.110941. Epub ahead of print. PMID: 39608055.
2)

Assumpcao de Monaco B, Benjamin CG, Doomi A, Taylor R, Stringfellow CE, Benveniste RJ, Jagid JR, Graciolli Cordeiro J. Safety Analysis of a New Portable Electrical Drill With a Smart Autostop Mechanism for Bedside Cranial Procedures. Oper Neurosurg (Hagerstown). 2023 Oct 1;25(4):311-314. doi: 10.1227/ons.0000000000000804. Epub 2023 Aug 4. PMID: 37543731; PMCID: PMC10468110.

Endovascular Treatment of Patients With Acute Ischemic Stroke With Tandem Lesions Presenting With Low Alberta Stroke Program Early Computed Tomography Score

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The study “Endovascular Treatment of Patients With Acute Ischemic Stroke With Tandem Lesions Presenting With Low Alberta Stroke Program Early Computed Tomography Score” published in *J Am Heart Assoc* presents a retrospective analysis of endovascular thrombectomy (ET) in patients with acute ischemic stroke and tandem lesions. Despite its timely and relevant focus on a niche aspect of stroke treatment, the article suffers from several critical shortcomings that weaken its impact and utility in advancing clinical practice.

First, the methodology lacks rigor in several areas. While the authors employed inverse probability of treatment weighting (IPTW) to balance groups with different ASPECTS scores, this statistical approach is fraught with challenges. IPTW can only partially adjust for confounding variables and may still introduce biases that distort the relationship between treatment and outcomes. Additionally, the reliance on retrospective data from 16 centers raises concerns about the generalizability of the findings. The data, while extensive, are retrospective and not prospective, which significantly limits the strength of the conclusions.

Second, the outcomes presented, including symptomatic intracranial hemorrhage (sICH) and functional independence, are not analyzed in depth concerning potential confounders such as the timing of thrombectomy, variation in procedural expertise, and differences in patient management. Although the study finds that patients with low ASPECTS (0-5) have lower odds of functional recovery and higher odds of sICH, this oversimplification disregards the nuances that may impact outcomes in real-world clinical settings. The reported odds ratios (ORs) for functional recovery and sICH (0.48 and 3.78, respectively) do little to guide clinical decision-making, as they fail to explore the complexity of individual patient characteristics and treatment variables.

The suggestion that 30% of patients with low ASPECTS may still achieve functional independence should be viewed with caution. This result, while intriguing, is buried in a sea of statistical averages that gloss over the heterogeneity of stroke severity and treatment response. What does this functional independence mean in terms of quality of life for patients with low ASPECTS, and how does it compare to other treatment modalities or supportive care? These critical questions are left unaddressed.

Moreover, the paper glosses over the limitations of the study design, particularly the lack of standardization across the centers involved. Given the variability in treatment protocols and the experience of clinicians at each site, it’s difficult to draw definitive conclusions about the efficacy of ET in this cohort. The authors also fail to explore alternative explanations for the increased risk of sICH observed in the low ASPECTS group, such as the potential role of comorbidities or pre-existing vascular conditions.

The study’s conclusions also need more nuance. While it correctly notes that the low ASPECTS cohort faces worse outcomes, the implication that ET should be withheld from these patients due to “reduced odds of functional recovery” is problematic. Clinical decision-making in acute stroke care must consider the individual patient’s potential for recovery, comorbidities, and the risks associated with other interventions. A blanket recommendation against ET for low ASPECTS patients would be premature and overly simplistic, particularly in light of the 30% functional independence rate reported.

In summary, while the study addresses an important clinical question, its methodological flaws, lack of depth in analysis, and failure to consider confounding factors significantly diminish its value. The paper offers limited insight for clinicians faced with treating patients with low ASPECTS and tandem lesions, and its conclusions require careful interpretation before being applied in practice.

Mapping the global neurosurgical workforce

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Critical Review of: “Mapping the global neurosurgical workforce. 

The article “Mapping the global neurosurgery workforce. Part 1: Consultant neurosurgeon density,” published in *the Journal of Neurosurgery*, provides an ambitious attempt to quantify and map the global distribution of neurosurgeons. While the study sheds light on global disparities, it fails to deliver in multiple crucial areas, from methodological flaws to missed opportunities for impactful analysis and actionable solutions. Ultimately, the article’s findings feel shallow and underdeveloped, leaving significant gaps in understanding and addressing the real challenges in neurosurgery workforce expansion.

1. Lack of Rigorous Data Collection and Methodology

At the heart of any robust study lies the quality of the data collection process, and this is where the study falters. The authors relies heavily on “personal contacts” and “online searches” to identify survey participants. This non-rigorous, subjective approach to participant selection creates room for considerable bias. In a global study of this magnitude, using personal networks and unverified online sources compromises the reliability and representativeness of the data. For instance, countries with fewer or no strong neurosurgical networks could easily be overlooked, thus skewing the results. Moreover, the authors mention “electronic cross-sectional surveys” but do not provide a clear description of how non-respondents were handled, leading one to question whether the sample is truly reflective of the global workforce. The data gathered through such an ad hoc, unsystematic process cannot be trusted to form the foundation of a serious, scientific inquiry into global neurosurgery density.

2. Overemphasis on High-Income Countries (HICs)

While the study points out the disparities in neurosurgery workforce density between low-, middle-, and high-income countries, it spends far too much time reiterating what is already well known: that high-income countries have significantly more neurosurgeons per capita than low-income countries. At a time when the global health community is grappling with health inequalities, this basic observation does little to advance our understanding. The study highlights the numbers (e.g., 2.44 neurosurgeons per 100,000 people in HICs versus 0.12 in low-income countries) without digging deeper into the underlying causes of these disparities or offering substantial policy recommendations. The authors fail to explore how specific health system characteristics—such as political will, international aid, and government healthcare priorities—shape these disparities. Instead, they leave the reader with numbers and little context for how to address these gaps.

3. Superficial Analysis of Regional Disparities

While the paper acknowledges that the African and Southeast Asia regions have the lowest densities of neurosurgeons, it misses the opportunity to explore the social, political, and economic factors that contribute to this situation. The study simply mentions that “countries with higher income-level designations had more frequent access to resources,” without further dissection. What does “access to resources” really mean? How do governmental policies, international funding, and the prioritization of neurosurgery differ between these regions? How do factors such as local infrastructure, training capacity, and healthcare access play a role in shaping workforce densities? These are critical questions that go unanswered in the paper. The superficial analysis of these disparities gives the impression that the study is more focused on confirming preconceived notions than on uncovering the root causes of inequities in neurosurgery training and practice.

4. Lack of Actionable Recommendations

The study falls short of offering any substantial recommendations to address the glaring gaps in the global neurosurgery workforce. It mentions the correlation between the presence of a neurosurgery society and workforce growth, but this observation is left unexplored. What can be done to create or strengthen neurosurgical societies in underrepresented regions? What specific interventions could rapidly increase neurosurgeon training or resource allocation? The study does not offer concrete strategies for reducing the workforce disparities between high- and low-income countries or improving the infrastructure for neurosurgery in regions with significant gaps. This lack of actionable insights severely weakens the article’s potential impact. At best, it is a descriptive study; at worst, it is an academic exercise that fails to move the needle on the global neurosurgical crisis.

5. Inconsistent and Shallow Statistical Analysis

The study conducts a regression analysis to explore the factors associated with workforce growth, which is an admirable attempt to analyze correlations. However, the presentation of this analysis is shallow, and its implications are underexplored. For example, the authors identify that “increasing global development aid” is associated with neurosurgeon growth, yet they do not discuss how or why this aid contributes to workforce expansion. Is it due to targeted funding for education, infrastructure, or equipment? The lack of detailed interpretation of the regression results leaves the reader with a set of statistical relationships that are not fully explained or contextualized.

6. Missed Opportunity for Global Collaboration and Solutions

What is most disappointing about this study is its failure to leverage the potential for global collaboration to address the crisis. The authors briefly mentions the presence of national neurosurgery societies, but they do not explore how international partnerships, such as those between organizations like the World Federation of Neurosurgical Societies (WFNS) and local governments, could drive workforce expansion. They also miss a critical opportunity to discuss how global networks and knowledge-sharing platforms could be used to help bridge the training gaps. At a time when digital platforms, telemedicine, and international collaborations are increasingly seen as solutions to global health challenges, the study neglects to discuss these possibilities.

Conclusion

In conclusion, the study “Mapping the global neurosurgery workforce. Part 1: Consultant neurosurgeon density” provides an overview of the state of the neurosurgery workforce, but it fails to live up to its potential. The methodology is flawed, the analysis is superficial, and the lack of actionable recommendations makes the study feel like an academic exercise rather than a meaningful contribution to addressing the global neurosurgery crisis. The study’s narrow focus on high-income countries, combined with an insufficient examination of the root causes of regional disparities, leaves much to be desired. To truly make an impact, future research should go beyond the numbers, offering in-depth insights into the systemic barriers that contribute to the neurosurgery workforce gaps and proposing concrete, sustainable solutions for equitable workforce growth worldwide.

The article “Mapping the global neurosurgery workforce. Part 2: Trainee density,” published in *Journal of Neurosurgery*, offers a broad analysis of the distribution and density of neurosurgery trainees worldwide, using a dataset drawn from 187 countries and 25 additional territories, states, and disputed regions. Although the study provides a valuable overview of the global state of neurosurgical training, it suffers from significant limitations and shortcomings in its methodology, analysis, and impact.

1. Methodological Weaknesses

While the authors claim to have surveyed all 193 countries and 26 territories, the methodology for data collection raises concerns. The study’s reliance on “personal contacts” of coauthors and “bibliometric and search engine searches” to identify participants undermines its credibility. The absence of a clear, systematic, or independent verification process for participant inclusion could introduce bias, leading to the exclusion of underrepresented regions or training programs that may not have direct links to prominent neurosurgical societies. This potential sampling bias compromises the validity of the data, especially when making conclusions about global neurosurgical training.

2. Disproportionate Focus on High-Income Countries (HICs)

The study’s findings reveal a striking disparity in trainee density, with high-income countries (HICs) dominating the global landscape of neurosurgery training. While the data from these regions may seem compelling, the disproportionate focus on HICs (with a density of 0.48 trainees per 100,000 people) fails to address the systemic barriers that exist in low-income countries (LICs) and middle-income countries (MICs). The authors provide an extensive comparison of regions but fail to fully explore the reasons behind these disparities. More emphasis should have been placed on why LICs have such limited access to training resources like cadaver laboratories and subspecialty training. By glossing over these issues, the article misses an opportunity to spark deeper discussions on the global inequities in neurosurgery training.

3. Lack of Depth in Analysis of Accreditation and Training Standards

Another critical flaw in the article is its cursory treatment of accreditation processes. While the authors mention that accreditation is more common in HICs than in LICs and MICs, they do not provide enough context on how accreditation impacts training quality. For instance, how do variations in accreditation standards between countries influence the readiness and competence of neurosurgeons entering the workforce? Without a more nuanced analysis of the accreditation systems, including the role of international bodies like the WFNS and EANS, the study misses an important aspect of quality assurance in neurosurgical education.

4. Limited Discussion on Sustainable Solutions

The study rightly identifies disparities in trainee density and resource availability between regions. However, the authors fail to offer substantial recommendations or solutions to address these inequities. Given the critical importance of sustainable neurosurgical education in improving patient outcomes, the article would have benefited from a more robust exploration of global initiatives, partnerships, and funding mechanisms that could help address these gaps. Merely presenting the data without a forward-thinking approach to solving the challenges does little to drive the field of global neurosurgery forward.

5. Failure to Address the Broader Context

While the study provides a valuable snapshot of trainee density, it lacks any significant engagement with the broader socioeconomic, political, and cultural factors that influence neurosurgery training worldwide. For example, in LICs, the availability of neurosurgery training is not just a question of resources but also political will, governance, and the overall health system infrastructure. This oversight makes the conclusions feel somewhat superficial, as the authors do not sufficiently interrogate the broader structural determinants of the observed disparities.

Conclusion

In summary, while *J Neurosurg*’s study offers a broad overview of neurosurgery trainee density globally, it falls short in several critical areas. Its methodology suffers from potential biases, its analysis of global disparities lacks depth, and its conclusions do little to suggest actionable solutions to the pressing issues it highlights. As a result, while the article provides some useful information, it ultimately fails to live up to the importance of the topic it tackles. More rigorous, nuanced, and solution-oriented work is needed to effectively map and address the challenges in global neurosurgical training.

Neurosurgery

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Definition

Neurosurgery is a surgical specialty focused on the diagnosis, treatment, and management of disorders affecting the nervous system, including the brain, spinal cord, and peripheral nerves.

It is a highly specialized field within medicine, and these procedures are typically performed by neurosurgeons who have extensive training and expertise in the diagnosis and treatment of neurological disorders.

Neurosurgeons

see Neurosurgeons.

Neurosurgical Diseases

Neurosurgical diseases.

Neurosurgical Procedure

Neurosurgical Procedure.

Neurosurgical Education

Neurosurgical Education.

Neurosurgical Training

Neurosurgical Training.

Technology and Innovation: Neurosurgery has seen significant advancements in recent years, thanks to the development of minimally invasive techniques, computer-assisted navigation, and neuroimaging technologies like MRI and CT scans. These innovations have improved the precision and safety of neurosurgical procedures.

Collaboration.

Subspecialties: Within neurosurgery, some subspecialties focus on specific areas, such as pediatric neurosurgery, functional neurosurgery (treating conditions like Parkinson’s disease), and neuro-oncology (treating brain and spinal cord tumors).

Neurosurgery (or neurological surgery), constitutes a medical discipline and surgical specialty that provides care for adult and pediatric patients in the treatment of pain or pathological processes that may modify the function or activity of the central nervous system (e.g. brain, hypophysis, and spinal cord), the peripheral nervous system (e.g. cranial, spinal, and peripheral nerves), the autonomic nervous system, the supporting structures of these systems (e.g. meninges, skull & skull base, and vertebral column), and their vascular supply (e.g. intracranial, extracranial, and spinal vasculature).

Treatment encompasses both non-operative management (e.g. prevention, diagnosis – including image interpretation – and treatments such as but not limited to neurocritical intensive care and rehabilitation) and operative management with its associated image use and interpretation (e.g. endovascular surgery, functional and restorative surgery, stereotactic radiosurgery, and spinal fusion – including its instrumentation.

They require precise and dexterous manipulation of a surgical suture in narrow and deep spaces in the brain. This is necessary for surgical tasks such as the anastomosis of microscopic blood vessels and dura mater suturing.

Neurosurgical procedures lead to great psychological stress. In the past decade, several strategies and techniques have been implemented to minimize the patient’s emotional stress 1) 2).

The esthetic aspect, not considered so important in the past, is now an important feature in the recovery and the quality of life in the postoperative period 3)

Today, neurosurgery is part of the portfolio of all university hospitals. It is a highly specialized service that, because of high costs, is often centralized.

Neurosurgery is one of the fastest-developing medical specialties, and results are continuously improving through the introduction of new treatment methods. Recent major advancements in neurosurgery include the application of microsurgery, the advancements in Imaging techniques, and the high quality and increased amount of a intensive care unit.

To improve the cost transparency of the local health care system, treatment cost was recently referenced to disease related groups (DRG). To define a valid case mix index (CMI), patient status at admission must be well documented. Concurrently, treatment quality must be closely monitored to provide transparency between health care providers concerning the clinical outcome and the complications during the treatment process 4) 5) 6).

Subspecialties

Neurosurgery Subspecialties.

History

see Neurosurgery History.

Books

see Books.

Journal

Neurosurgery Journal

see Neurosurgery Journal

Impact factor: 4.605 (2018)

Future

Globally, the lack of access to basic surgical care causes 3 times as many deaths as HIV/AIDS, tuberculosis, and malaria combined. The magnitude of this unmet need has been described recently, and the numbers are startling. Major shifts in the global health agenda have highlighted access to essential and emergency surgery as a high priority. A broad examination of the current global neurosurgical efforts to improve access has revealed some strengths, particularly in the realm of training; however, the demand grossly outstrips the supply; Most people in low-income countries do not have access to basic surgical care, either due to lack of availability or affordability. Projects that help create a robust and resilient health system within low- and middle-income countries require urgent implementation. In this context, concurrent scale-up of human resources, investments in capacity building, local data collection, and analysis for accurate assessment are essential. In addition, through the process of collaboration and consensus building within the neurosurgical community, a unified voice of neurosurgery is necessary to effectively advocate for all those who need neurosurgical care wherever, whenever 7).

1) 

Angelini GD, Butchart EG, Armistead SH, Breckenridge IM. Comparative study of leg wound skin closure in coronary artery bypass graft operations. Thorax. 1984;39:942–5.

2) 

Bekar A, Korfali E, Dogan S, Yilmazlar S, Baskan Z, Aksoy K. The effect of hair on infection after cranial surgery. Acta Neurochir (Wien) 2001;143:533–6. discussion 537.

3) 

Cho J, Harrop J, Veznaedaroglu E, Andrews DW. Concomitant use of computer image guidance, linear or sigmoid incisions after minimal shave, and liquid wound dressing with 2-octyl cyanoacrylate for tumor craniotomy or craniectomy: Analysis of 225 consecutive surgical cases with antecedent historical control at one institution. Neurosurgery. 2003;52:832–40. discussion 840-1.

4) 

Clark JC, Spetzler RF. Creating a Brave New World for Neurosurgery. World Neurosurgery. 2011; 75 (5):608–9. doi: 10.1016/j.wneu.2010.12.032

5) 

Scho¨b O, Kocher T, Langer I. Fu¨nf Fragen an die Medizinische Qualita¨tssicherung: Die Selbststeuerung erhalten. Bulletin des me´decins suisses. 2014; 95(39):1446–8.

6) 

OECD/WHO. OECD Reviews of Health Systems: Switzerland 2011.

7) 

Park KB, Johnson WD, Dempsey RJ. Global Neurosurgery: The Unmet Need. World Neurosurg. 2016 Apr;88:32-5. doi: 10.1016/j.wneu.2015.12.048. Epub 2015 Dec 28. PubMed PMID: 26732963.