Publications by authors named "Jacob Lepard"

39 Publications

An Assessment of Global Neurotrauma Prevention and Care Delivery: The Provider Perspective.

World Neurosurg 2021 Sep 21. Epub 2021 Sep 21.

Program in Global Surgery and Social Change, Harvard University, Boston, MA, USA.

Introduction: Neurotrauma is one of the leading causes of morbidity and mortality around the world. Assessment of injury prevention and pre-hospital care for neurotrauma patients is necessary to improve care systems.

Methods: A 29-question electronic survey was developed based on the EQUATOR checklist to assess neurotrauma policies and laws related to safety precautions. The survey was distributed to members of WHO regions that were considered to be experienced medical authorities in neurosurgery and traumatic brain injury (TBI).

Results: There were 82 (39%) responses, which represented 46 different countries. Almost all respondents (95.2%) were within the neurosurgical field. 40.2% of respondents were from HICs and 59.8% from LMICs. Motor vehicle accidents (MVAs) were reported as the leading cause of neurotrauma, with workplace injury ranking second, and assault third. 84.1% of respondents reported having a helmet law in their country. HICs (4.38 ±0.78) were ranked more likely than LMICs (2.88 ±1.34, p=0.0001) to enforce helmet laws, on a scale of 1-10. The effectiveness of helmet laws was rated as 3.94 ±0.95 out of 10, on average. Measures regarding pre-hospital care varied between HICs and LMICs. Patients in HICs were more likely to utilize public emergency ambulance transportation (81.8% vs 42.9%; p=0.0004). The presence of all pre-hospital personnel having emergency training was also reported to be more likely in HICs than LMICs (60.6% vs 8.7%, p=0.0001).

Conclusion: When injuries occur, timely access to neurosurgical care is critical and requires improvement of all aspects of the system. Accordingly, a focus on pre-hospital components of the trauma system is paramount, and policymakers can utilize the information here to implement and refine healthcare systems that will ensure safe, timely, affordable, and equitable access to neurotrauma care.
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http://dx.doi.org/10.1016/j.wneu.2021.09.025DOI Listing
September 2021

Differences in outcomes of mandatory motorcycle helmet legislation by country income level: A systematic review and meta-analysis.

PLoS Med 2021 Sep 17;18(9):e1003795. Epub 2021 Sep 17.

Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America.

Background: The recent Lancet Commission on Legal Determinants of Global Health argues that governance can provide the framework for achieving sustainable development goals. Even though over 90% of fatal road traffic injuries occur in low- and middle-income countries (LMICs) primarily affecting motorcyclists, the utility of helmet laws outside of high-income settings has not been well characterized. We sought to evaluate the differences in outcomes of mandatory motorcycle helmet legislation and determine whether these varied across country income levels.

Methods And Findings: A systematic review and meta-analysis were completed using the PRISMA checklist. A search for relevant articles was conducted using the PubMed, Embase, and Web of Science databases from January 1, 1990 to August 8, 2021. Studies were included if they evaluated helmet usage, mortality from motorcycle crash, or traumatic brain injury (TBI) incidence, with and without enactment of a mandatory helmet law as the intervention. The Newcastle-Ottawa Scale (NOS) was used to rate study quality and funnel plots, and Begg's and Egger's tests were used to assess for small study bias. Pooled odds ratios (ORs) and their 95% confidence intervals (CIs) were stratified by high-income countries (HICs) versus LMICs using the random-effects model. Twenty-five articles were included in the final analysis encompassing a total study population of 31,949,418 people. There were 17 retrospective cohort studies, 2 prospective cohort studies, 1 case-control study, and 5 pre-post design studies. There were 16 studies from HICs and 9 from LMICs. The median NOS score was 6 with a range of 4 to 9. All studies demonstrated higher odds of helmet usage after implementation of helmet law; however, the results were statistically significantly greater in HICs (OR: 53.5; 95% CI: 28.4; 100.7) than in LMICs (OR: 4.82; 95% CI: 3.58; 6.49), p-value comparing both strata < 0.0001. There were significantly lower odds of motorcycle fatalities after enactment of helmet legislation (OR: 0.71; 95% CI: 0.61; 0.83) with no significant difference by income classification, p-value: 0.27. Odds of TBI were statistically significantly lower in HICs (OR: 0.61, 95% CI 0.54 to 0.69) than in LMICs (0.79, 95% CI 0.72 to 0.86) after enactment of law (p-value: 0.0001). Limitations of this study include variability in the methodologies and data sources in the studies included in the meta-analysis as well as the lack of available literature from the lowest income countries or from the African WHO region, in which helmet laws are least commonly present.

Conclusions: In this study, we observed that mandatory helmet laws had substantial public health benefits in all income contexts, but some outcomes were diminished in LMIC settings where additional measures such as public education and law enforcement might play critical roles.
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http://dx.doi.org/10.1371/journal.pmed.1003795DOI Listing
September 2021

Early implementation of stereoelectroencephalography in children: a multiinstitutional case series.

J Neurosurg Pediatr 2021 Sep 3:1-8. Epub 2021 Sep 3.

1Department of Neurological Surgery, University of Alabama at Birmingham, Alabama.

Objective: Pediatric stereoelectroencephalography (SEEG) has been increasingly performed in the United States, with published literature being limited primarily to large single-center case series. The purpose of this study was to evaluate the experience of pediatric epilepsy centers, where the technique has been adopted in the last several years, via a multicenter case series studying patient demographics, outcomes, and complications.

Methods: A retrospective cohort methodology was used based on the STROBE criteria. ANOVA was used to evaluate for significant differences between the means of continuous variables among centers. Dichotomous outcomes were assessed between centers using a univariate and multivariate logistic regression.

Results: A total of 170 SEEG insertion procedures were included in the study from 6 different level 4 pediatric epilepsy centers. The mean patient age at time of SEEG insertion was 12.3 ± 4.7 years. There was no significant difference between the mean age at the time of SEEG insertion between centers (p = 0.3). The mean number of SEEG trajectories per patient was 11.3 ± 3.6, with significant variation between centers (p < 0.001). Epileptogenic loci were identified in 84.7% of cases (144/170). Patients in 140 cases (140/170, 82.4%) underwent a follow-up surgical intervention, with 47.1% (66/140) being seizure free at a mean follow-up of 30.6 months. An overall postoperative hemorrhage rate of 5.3% (9/170) was noted, with patients in 4 of these cases (4/170, 2.4%) experiencing a symptomatic hemorrhage and patients in 3 of these cases (3/170, 1.8%) requiring operative evacuation of the hemorrhage. There were no mortalities or long-term complications.

Conclusions: As the first multicenter case series in pediatric SEEG, this study has aided in establishing normative practice patterns in the application of a novel surgical technique, provided a framework for anticipated outcomes that is generalizable and useful for patient selection, and allowed for discussion of what is an acceptable complication rate relative to the experiences of multiple institutions.
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http://dx.doi.org/10.3171/2021.5.PEDS20923DOI Listing
September 2021

Nonsyndromic craniosynostosis in Vietnam: initial surgical outcomes of subspecialty mentorship.

J Neurosurg Pediatr 2021 Aug 27:1-8. Epub 2021 Aug 27.

3Department of Neurological Surgery, University of Alabama at Birmingham, Birmingham, Alabama.

Objective: There is a global deficit of pediatric neurosurgical care, and the epidemiology and overall surgical care for craniosynostosis is not well characterized at the global level. This study serves to highlight the details and early surgical results of a neurosurgical educational partnership and subsequent local scale-up in craniosynostosis correction.

Methods: A prospective case series was performed with inclusion of all patients undergoing correction of craniosynostosis by extensive cranial vault remodeling at Children's Hospital 2, Ho Chi Minh City, Vietnam, between January 1, 2015, and December 31, 2019.

Results: A total of 76 patients were included in the study. The group was predominantly male, with a male-to-female ratio of 3.3:1. Sagittal synostosis was the most common diagnosis (50%, 38/76), followed by unilateral coronal (11.8%, 9/76), bicoronal (11.8%, 9/76), and metopic (7.9%, 6/76). The most common corrective technique was anterior cranial vault remodeling (30/76, 39.4%) followed by frontoorbital advancement (34.2%, 26/76). The overall mean operative time was 205.8 ± 38.6 minutes, and the estimated blood loss was 176 ± 89.4 mL. Eleven procedures were complicated by intraoperative durotomy (14.5%, 11/76) without any damage of dural venous sinuses or brain tissue. Postoperatively, 4 procedures were complicated by wound infection (5.3%, 4/76), all of which required operative wound debridement. There were no neurological complications or postoperative deaths. One patient required repeat reconstruction due to delayed intracranial hypertension. There was no loss to follow-up. All patients were followed at outpatient clinic, and the mean follow-up period was 32.3 ± 18.8 months postoperatively.

Conclusions: Surgical care for pediatric craniosynostosis can be taught and sustained in the setting of collegial educational partnerships with early capability for high surgical volume and safe outcomes. In the setting of the significant deficit in worldwide pediatric neurosurgical care, this study provides an example of the feasibility of such relationships in addressing this unmet need.
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http://dx.doi.org/10.3171/2021.5.PEDS20932DOI Listing
August 2021

Comparison of aesthetic outcomes between open and endoscopically treated sagittal craniosynostosis.

J Neurosurg Pediatr 2021 Jul 30:1-7. Epub 2021 Jul 30.

Departments of1Neurological Surgery and.

Objective: In the last several decades, there has been much debate regarding the ideal treatment for sagittal synostosis. The purpose of this study was to compare perioperative, anthropometric, and subjective assessments of cosmetic outcomes between open and endoscopic management of isolated sagittal synostosis.

Methods: At their routine postoperative follow-up, pediatric patients with sagittal craniosynostosis were recruited to undergo digital cranial measurement and standardized photography for objective and subjective assessments of perioperative outcomes. Age-normalized z-scores for cephalic index, head circumference, euryon-euryon diameter (Eu-Eu), and glabella-opisthocranion diameter (G-Op) were calculated for each patient. Faculty surgeons, surgical trainees, nurses, and laypersons were asked to rate the normalcy of craniofacial appearances using a 5-point Likert scale. Outcomes were compared between patients treated with endoscopic correction and those treated with open repair.

Results: A total of 50 patients were included in the study. Thirty-one had undergone open surgical correction, and 19 had undergone endoscopic treatment. Endoscopic repair involved significantly lower operative time, blood loss, transfusion rate, and hospital length of stay than those with open repair (p < 0.001). There was no significant difference between groups in terms of z-scores for head circumference (p = 0.22), cephalic index (p = 0.25), or Eu-Eu (p = 0.38). Endoscopic treatment was associated with a significantly lower G-Op (p = 0.009). Additionally, the average subjective rating of head shape was higher for endoscopic treatment when corrected for age, gender, and ethnicity (p = 0.02).

Conclusions: The study findings suggest that patients who are treated endoscopically may have an overall more normal appearance in skull morphology and cosmesis, although these results are limited by poor reliability.
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http://dx.doi.org/10.3171/2021.3.PEDS20894DOI Listing
July 2021

Variation in pediatric stereoelectroencephalography practice among pediatric neurosurgeons in the United States: survey results.

J Neurosurg Pediatr 2021 Jun 18:1-9. Epub 2021 Jun 18.

4Division of Pediatric Neurosurgery, Department of Neurosurgery, Children's of Alabama, University of Alabama at Birmingham, Alabama.

Objective: Stereoelectroencephalography (SEEG) has become widespread in the United States during the past decade. Many pediatric neurosurgeons practicing SEEG may not have had experience with this technique during their formal training, and the literature is mostly limited to single-center series. As a result, implementation of this relatively new technique may vary at different institutions. The authors hypothesized that aspects of SEEG experience, techniques, and outcomes would vary widely among programs across the country.

Methods: An electronic survey with 35 questions addressing the categories of training and experience, technique, electrode locations, and outcomes was sent to 128 pediatric epilepsy surgeons who were potential SEEG users.

Results: Sixty-one pediatric fellowship-trained epilepsy surgeons in the United States responded to the survey. Eighty-nine percent were actively using SEEG in their practice. Seventy-two percent of SEEG programs were in existence for less than 5 years, and 68% were using SEEG for > 70% of their invasive monitoring. Surgeons at higher-volume centers operated on younger patients (p < 0.001). Most surgeons (70%) spent 1-3 hours per case planning electrode trajectories. Two-thirds of respondents reported a median implant duration of 5-7 days, but 16% reported never having an implant duration > 5 days, and 16% reported having had implants stay in place for > 4 weeks. The median response for the median number of electrodes initially implanted was 12 electrodes, although 19% of respondents reported median implants of 5-8 electrodes and 17% reported median implants of 15-18 electrodes. Having a higher volume of SEEG cases per year was associated with a higher median number of electrodes implanted (p < 0.001). Most surgeons found SEEG helpful in defining an epileptic network and reported that most of their SEEG patients undergo focal surgical treatment.

Conclusions: SEEG has been embraced by the pediatric epilepsy surgery community. Higher case volume is correlated with a tendency to place more electrodes and operate on younger patients. For most parameters addressed in the survey, responses from surgeons clustered around a norm, though additional findings of substantial variations highlight differences in implementation and philosophy among pediatric epilepsy programs.
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http://dx.doi.org/10.3171/2021.1.PEDS20799DOI Listing
June 2021

Surgically treatable adult epilepsy: a changing patient population. Experience from a level 4 epilepsy center.

J Neurosurg 2021 May 28:1-6. Epub 2021 May 28.

Departments of1Neurosurgery and.

Objective: Invasive monitoring has long been utilized in the evaluation of patients for epilepsy surgery, providing localizing information to guide resection. Stereoelectroencephalography (SEEG) was introduced at the authors' level 4 epilepsy surgery program in 2013, with responsive neurostimulation (RNS) becoming available the following year. The authors sought to characterize patient demographics and epilepsy-related variables before and after SEEG introduction to understand whether differences emerged in their patient population. This information will be useful in understanding how SEEG, possibly in conjunction with RNS availability, may have changed practice patterns over time.

Methods: This is a retrospective cohort study of consecutive patients who underwent surgery for epilepsy from 2006 to 2018, comprising 7 years before and 5 years after the introduction of SEEG. The authors performed univariate analyses of patient characteristics and outcomes and used generalized estimating equations logistic regression for predictive analysis.

Results: A total of 178 patients were analyzed, with 109 patients in the pre-SEEG cohort and 69 patients in the post-SEEG cohort. In the post-SEEG cohort, more patients underwent invasive monitoring for suspected bilateral seizure onsets (40.6% vs 22.0%, p = 0.01) and extratemporal seizure onsets (68.1% vs 8.3%, p < 0.0001). The post-SEEG cohort had a higher proportion of patients with seizures arising from eloquent cortex (14.5% vs 0.9%, p < 0.001). Twelve patients underwent RNS insertion in the post-SEEG group versus none in the pre-SEEG group. Fewer patients underwent resection in the post-SEEG group (55.1% vs 96.3%, p < 0.0001), but there was no significant difference in rates of seizure freedom between cohorts for those patients having undergone a follow-up resection (53.1% vs 59.8%, p = 0.44).

Conclusions: These findings demonstrate that more patients with suspected bilateral, eloquent, or extratemporal epilepsy underwent invasive monitoring after adoption of SEEG. This shift occurred coincident with the adoption of RNS, both of which likely contributed to increased patient complexity. The authors conclude that their practice now considers invasive monitoring for patients who likely would not previously have been candidates for surgical investigation and subsequent intervention.
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http://dx.doi.org/10.3171/2020.10.JNS201629DOI Listing
May 2021

Rare Ameloblastic Carcinoma Metastasis to the Cervical Spine: A Case Report.

Neurosurgery 2021 05;88(6):E537-E542

Department of Neurosurgery, University of Alabama at Birmingham Hospital, Birmingham, Alabama, USA.

Background And Importance: Ameloblastic carcinoma (AC) is a malignant neoplasm of epithelial origin that typically arises from the mandible or maxilla. It represents approximately 2% of all odontogenic tumors. Gross total resection is the surgical goal given AC's aggressiveness and propensity for recurrence. We present the first reported AC metastasis to the cervical spine.

Clinical Presentation: A 61-yr-old African American female with a history of AC of bilateral mandibles and lung metastases presented with neck pain and right arm weakness progressive over several months. Cervical spine imaging demonstrated a cervical 3 pathological fracture with severe anterior vertebral body compression and resultant cervical 2-3 kyphotic deformity and bony retropulsion causing severe cord compression. The patient underwent a cervical 3 corpectomy and cervical 2-4 anterior fixation followed by a cervical 3 laminectomy and cervical 2-5 dorsal internal fixation and fusion. Postoperatively, the patient's neurological exam remained stable and imaging showed improved spinal alignment and appropriate anterior and posterior instrumentation. Unfortunately, the patient thereafter suffered a decline in performance status and progression of lung metastatic disease. Her oncology team is considering chemotherapy and stereotactic radiosurgery, but her prognosis remains grim.

Conclusion: AC is a rare and aggressive pathology with a poor prognosis despite multimodal therapy. We present the first case of AC metastatic spread to the spine. We aim to bring this pathology to the attention of our worldwide neurosurgical colleagues and share our surgical approach and multidisciplinary management to assist those who may encounter this pathology in the future.
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http://dx.doi.org/10.1093/neuros/nyab044DOI Listing
May 2021

In Reply to the Letter to the Editor Regarding "The Resident's Role in Global Neurosurgery".

World Neurosurg 2021 02;146:433

Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee, USA.

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http://dx.doi.org/10.1016/j.wneu.2020.11.053DOI Listing
February 2021

Objective Craniometric Versus Subjective Outcome Ratings in Endoscopic and Open Sagittal Synostosis Surgery.

J Craniofac Surg 2021 Jan 28. Epub 2021 Jan 28.

Department of Neurosurgery Department of Surgery, Division of Plastic Surgery, University of Alabama at Birmingham, AL Department of Neurosurgery, Penn State College of Medicine, Hershey, PA.

Background: Despite advances in surgical treatments and assessments of objective outcomes in surgery for sagittal synostosis, there is no agreement regarding the optimal assessment of postoperative outcomes. Additionally, few studies have evaluated subjective assessments of cranial morphology after surgical correction. This study sought to evaluate the utility of subjective aesthetic outcome assessment and compare these assessments to established craniometric outcomes in patients undergoing surgery for isolated sagittal synostosis.

Methods: Nineteen raters (5 parents, 4 surgeons, 5 trainees and 5 nurses) evaluated fifty patients who underwent surgical correction of isolated sagittal synostosis using standardized postoperative patient photos and a five-point Likert scale. Previously established anthropomorphic measurements were recorded postoperatively in these same patients and comparisons were made between the objective anthropomorphic and subjective outcome evaluations.

Results: There were no statistically significant correlations between age-controlled cephalic index, head circumference, or euryon-euryon diameter and subjective aesthetic scores. Lay persons assigned a significantly lower proportion of scores (37.9%) as middle values (2, 3, or 4) compared with faculty (64.8%). There was a statistically significant association between high scores given by surgical faculty and laypersons (P < 0.001).

Conclusions: Subjective measurement of cosmetic outcome is a useful metric in surgical correction of craniosynostosis. Although no correlations were found between objective measurements and subjective aesthetic scores, cosmetic assessments by surgeons demonstrated strong correlation with lay perception, indicating that these ratings may be a good gauge of overall cosmetic outcome. When used in combination, objective and subjective measurements provide unique value to assess outcomes after surgery for craniosynostosis.
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http://dx.doi.org/10.1097/SCS.0000000000007500DOI Listing
January 2021

The Resident's Role in Global Neurosurgery.

World Neurosurg 2020 08;140:403-405

Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee, USA; Department of Neurosurgery, Hospital for Sick Kids, Toronto, Ontario, Canada.

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http://dx.doi.org/10.1016/j.wneu.2020.06.004DOI Listing
August 2020

A model for global surgical training and capacity development: the Children's of Alabama-Viet Nam pediatric neurosurgery partnership.

Childs Nerv Syst 2021 02 27;37(2):627-636. Epub 2020 Jul 27.

Department of Neurological Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.

Introduction: Training capable and competent neurosurgeons to work in underserved regions of the world is an essential component of building global neurosurgical capacity. One strategy for achieving this goal is establishing longitudinal partnerships between institutions in low- and middle-income countries (LMICs) and their counterparts in high-income countries (HICs) utilizing a multi-component model. We describe the initial experience of the Children's of Alabama (COA) Global Surgery Program partnership with multiple Vietnamese neurosurgical centers.

Methods: The training model developed by the COA Global Surgery Program utilizes three complementary and interdependent methods to expand neurosurgical capacity: in-country training, out-of-country training, and ongoing support and mentorship. Multiple Vietnamese hospital systems have participated in the partnership, including three hospitals in Hanoi and one hospital in Ho Chi Minh City.

Results: During the 7 years of the partnership, the COA and Viet Nam teams have collaborated on expanding pediatric neurosurgical care in numerous areas of clinical need including five subspecialized areas of pediatric neurosurgery: cerebrovascular, epilepsy, neuroendoscopy for hydrocephalus management, craniofacial, and neuro-oncology.

Conclusion: Long-term partnerships between academic departments in LMICs and HICs focused on education and training are playing an increasingly important role in scaling up global surgical capacity. We believe that our multi-faceted approach consisting of in-country targeted hands-on training, out-of-country fellowship training at the mentor institution, and ongoing mentorship using telecollaboration and Internet-based tools is a viable and generalizable model for enhancing surgical capacity globally.
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http://dx.doi.org/10.1007/s00381-020-04802-4DOI Listing
February 2021

Letter: Neurosurgeons and Curves: The Need for Critical Appraisal of Modeling in the Post-COVID Era.

Neurosurgery 2020 09;87(4):E523-E524

Department of Neurosurgery University of Alabama at Birmingham Birmingham, Alabama.

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http://dx.doi.org/10.1093/neuros/nyaa298DOI Listing
September 2020

An online tumor board with international neurosurgical collaboration guides surgical decision-making in Western Kenya.

Childs Nerv Syst 2021 02 22;37(2):715-719. Epub 2020 Jun 22.

Department of Surgery, Tenwek Hospital, Bomet, Kenya.

Telecollaboration via web-based platforms has emerged as a tool to relieve constraints on the establishment of tumor boards for neurosurgical oncology. Challenging tumor cases arising in low- and middle-income countries may benefit from the use of such models. The case of a 5-year-old boy presenting in Western Kenya with a challenging tumor and symptomatic hydrocephalus was presented on a novel web platform to a multi-national audience of neurosurgeons. The treating neurosurgeon invited a physician network to review the case vignette and radiographic images. Respondents independently offered input during a prescribed response period. Three respondents provided surgical opinions during a 24-h response period. The treating neurosurgeon utilized the pooled input to determine a course of action for the patient. When a web-based platform is available, lone neurosurgeons in low-resource settings may nevertheless apply multi-national, multi-institutional perspectives to challenging oncology cases.
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http://dx.doi.org/10.1007/s00381-020-04744-xDOI Listing
February 2021

Neurosurgical resident research education: a survey of United States residency program directors.

J Neurosurg 2019 Oct 25:1-10. Epub 2019 Oct 25.

Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama.

Objective: The application of evidence-based medicine (EBM) has played an increasing role within neurosurgical education over the last several decades. The Accreditation Council for Graduate Medical Education (ACGME) has mandated that residents are now required to demonstrate academic productivity and mastery of EBM principles. The goal of this study was to assess how neurosurgery programs around the US are dealing with the challenges of fulfilling these program requirements from the ACGME in addition to standard neurosurgical education.

Methods: A 20-question survey was developed and electronically delivered to residency program directors of the 110 ACGME-approved MD and DO training programs in the US. Data regarding journal club and critical appraisal skills, research requirements, and protected research time were collected. Linear regression was used to determine significant associations between these data and reported resident academic productivity.

Results: Responses were received from 102 of the 110 (92.7%) neurosurgical training programs in the US. Ninety-eight programs (96.1%) confirmed a regularly scheduled journal club. Approximately half of programs (51.5%) indicated that the primary goal of their journal club was to promote critical appraisal skills. Only 58.4% of programs reported a formal EBM curriculum. In 57.4% of programs an annual resident publication requirement was confirmed. Multivariate regression models demonstrated that greater protected research time (p = 0.001), journal club facilitator with extensive training in research methods (p = 0.029), and earlier research participation during residency (p = 0.049) all increased the number of reported publications per resident.

Conclusions: Although specific measures are important, and should be tailored to the program, the overall training culture with faculty mentorship and provision of time and resources for research activity are probably the most important factors.

Abbreviations: ACGME = Accreditation Council for Graduate Medical Education; EBM = evidence-based medicine; PGY = postgraduate year.
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http://dx.doi.org/10.3171/2019.7.JNS19632DOI Listing
October 2019

Pediatric Neurosurgery in East Africa: An Education and Needs-Based Survey.

World Neurosurg 2020 09 23;141:e374-e382. Epub 2020 May 23.

Department of Neurosurgery, Northwestern University Feinberg School of Medicine and Lurie Children's Hospital, Chicago, Illinois, USA.

Introduction: A pediatric neurosurgery training workshop was organized for residents and consultants in East Africa. We aimed to compile feedback from the course participants to 1) characterize the state of neurosurgical education; and 2) identify the perceived practical education needs.

Methods: The survey of demographic, clinical background and practice, and feedback questions was distributed to all attendees. Responses were elicited via yes/no questions and Likert scales, with the score ranging from 1 (not important, not useful, never) to 5 (very important, very useful, often). The data were de-identified and analyzed in aggregate.

Results: A total of 11 neurosurgeons and trainees completed the survey, including 6 residents (55%) and 5 consultants (45%). Although 5 countries of origin were represented, all attendees (100%) have completed their neurosurgery training in Kenya. The respondents had most frequently treated trauma (least common to most common, 1-5; mean, 4.55 ± 0.93), hemorrhagic stroke (mean, 4.27 ± 0.79), and pediatric tumors (mean, 4.27 ± 1.01). In training, the most commonly used study resources were online resources (9; 82%), textbooks (7; 64%), and online lectures (7; 64%). The areas of greatest perceived need in education and training included general neurosurgery (least to most need, 1-10: 9; 82%), pediatric (9; 82%), trauma and neurocritical care (7; 64%), and neuro-oncology (7; 64%). All 11 respondents (100%) reported that more direct operative teaching was important for educational improvement. Hydrocephalus (least to most useful, 1-5: 5.00 ± 0.00), neuro-endoscopy (4.91 ± 0.30), and tumor (4.91 ± 0.30) were considered the most useful content covered in the pediatric neurosurgery-focused training program to improve skills and knowledge base.

Conclusions: The results from the present survey identified areas of education and training needs to guide further neurosurgical education efforts in East Africa.
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http://dx.doi.org/10.1016/j.wneu.2020.05.155DOI Listing
September 2020

Styloidogenic jugular venous compression syndrome: a case report and review of the literature.

Childs Nerv Syst 2020 12 28;36(12):3135-3139. Epub 2020 Apr 28.

Department of Neurosurgery, University of Alabama at Birmingham, 1802 6th Avenue South, FOT 1001, Birmingham, AL, 35233, USA.

Background: Styloidogenic jugular venous compression syndrome (SJVCS) has been shown to present with a similar symptomatology to idiopathic intracranial hypertension (IIH) and is caused by compression of the internal jugular vein (IJV) between the lateral tubercle of C1 and the styloid process. Treatments including venous stenting and styloidectomy have been reported with good outcomes; however, treatment of a pediatric patient with SJVCS with styloidectomy has not previously been reported in the literature.

Case Report: A 12-year-old male presented with refractory positional headaches, nausea, and vomiting, and after, workup including lumbar puncture (LP) and intracranial pressure (ICP) monitoring was found to have intracranial hypertension associated with contralateral neck turning. Computed tomography venogram (CTV) revealed severe bilateral compression of the IJV's between the styloid processes and C1 tubercle. The patient was successfully treated with unilateral right-sided styloidectomy with symptomatic relief.

Conclusions: This is the first reported pediatric case of SJVCS treated successfully with styloidectomy to our knowledge and adds to the limited literature that styloidectomy is a durable treatment option for SJVCS.
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http://dx.doi.org/10.1007/s00381-020-04622-6DOI Listing
December 2020

Training Neurosurgeons in Myanmar and Surrounding Countries: The Resident Perspective.

World Neurosurg 2020 07 3;139:75-82. Epub 2020 Apr 3.

Department of Neurosurgery, North Okkalapa Hospital, Yangon, Myanmar.

Introduction: In recent decades there has been a significant expansion of neurosurgical capabilities in low- and middle-income countries, particularly in Southeast Asia. Despite these developments, little is known about the structure and quality of local neurosurgical training paradigms.

Methods: A 36-question survey was administered to neurosurgical trainees in person at the Southeast Asian Neurosurgical Bootcamp to assess demographics, structure, and exposure of neurosurgical training in Southeast Asia.

Results: A total of 45 out of 47 possible respondents participated in the survey; 78% were men, with an age range of 26-40 years. Neurosurgical training most commonly consisted of 3 (n = 22, 49%) or 6 years (n = 14, 31%). The majority of respondents (70.5%) were from Myanmar, with the remainder coming from Indonesia, Cambodia, Thailand, and Nepal. Most residents (n = 38, 84%) used textbooks as their primary study resource. Only 24 (53%) residents indicated that they had free access to online neurosurgical journals via their training institution. The majority (n = 27, 60%) reported that fewer than 750 cases were performed at their institution per year; with a median of 70% (interquartile range: 50%-80%) being emergent. The most commonly reported procedures were trauma craniotomies and ventriculoperitoneal shunting. The least commonly reported procedures were endovascular techniques and spinal instrumentation.

Conclusions: Although the unmet burden of neurosurgical disease remains high, local training programs are devoting significant efforts to provide a sustainable solution to the problem of neurosurgical workforce. High-income country institutions should partner with global colleagues to ensure high-quality neurosurgical care for all people regardless of location and income.
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http://dx.doi.org/10.1016/j.wneu.2020.03.114DOI Listing
July 2020

Corrigendum to 'Comprehensive Policy Recommendations for Head and Spine Injury Care in Low- and Middle-Income Countries' [World Neurosurgery 132 (2019), 434-436].

World Neurosurg 2020 05 28;137:504. Epub 2020 Feb 28.

Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.

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http://dx.doi.org/10.1016/j.wneu.2020.02.046DOI Listing
May 2020

The CURE Protocol: evaluation and external validation of a new public health strategy for treating paediatric hydrocephalus in low-resource settings.

BMJ Glob Health 2020 23;5(2):e002100. Epub 2020 Feb 23.

Program for Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA.

Introduction: Managing paediatric hydrocephalus with shunt placement is especially risky in resource-limited settings due to risks of infection and delayed life-threatening shunt obstruction. This study evaluated a new evidence-based treatment algorithm to reduce shunt-dependence in this context.

Methods: A prospective cohort design was used. The CURE Protocol employs preoperative and intraoperative data to choose between endoscopic treatment and shunt placement. Data were prospectively collected for 730 children in Uganda (managed by local neurosurgeons highly experienced in the protocol) and, for external validation, 96 children in Nigeria (managed by a local neurosurgeon trained in the protocol).

Results: The age distribution was similar between Uganda and Nigeria, but there were more cases of postinfectious hydrocephalus in Uganda (64.2% vs 26.0%, p<0.001). Initial treatment of hydrocephalus was similar at both centres and included either a shunt at first operation or endoscopic management without a shunt. The Nigerian cohort had a higher failure rate for endoscopic cases (adjusted HR 2.5 (95% CI 1.6 to 4.0), p<0.001), but not for shunt cases (adjusted HR 1.3 (0.5 to 3.0), p=0.6). Despite the difference in endoscopic failure rates, a similar proportion of the entire cohort was successfully treated without need for shunt at 6 months (55.2% in Nigeria vs 53.4% in Uganda, p=0.74).

Conclusion: Use of the CURE Protocol in two centres with different populations and surgeon experience yielded similar 6-month results, with over half of all children remaining shunt-free. Where feasible, this could represent a better public health strategy in low-resource settings than primary shunt placement.
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http://dx.doi.org/10.1136/bmjgh-2019-002100DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7042585PMC
June 2021

The initial experience of InterSurgeon: an online platform to facilitate global neurosurgical partnerships.

Neurosurg Focus 2020 03;48(3):E15

1Department of Neurological Surgery, University of Alabama at Birmingham.

Objective: Despite general enthusiasm for international collaboration within the organized neurosurgical community, establishing international partnerships remains challenging. The current study analyzes the initial experience of the InterSurgeon website in partnering surgeons from across the world to increase surgical collaboration.

Methods: One year after the launch of the InterSurgeon website, data were collected to quantify the number of website visits, average session duration, total numbers of matches, and number of offers and requests added to the website each month. Additionally, a 15-question survey was designed and distributed to all registered members of the website.

Results: There are currently 321 surgeon and institutional members of InterSurgeon representing 69 different countries and all global regions. At the time of the survey there were 277 members, of whom 76 responded to the survey, yielding a response rate of 27.4% (76/277). Twenty-five participants (32.9%) confirmed having either received a match email (12/76, 15.8%) or initiated contact with another user via the website (13/76, 17.1%). As expected, the majority of the collaborations were either between a high-income country (HIC) and a low-income country (LIC) (5/18, 27.8%) or between an HIC and a middle-income country (MIC) (9/18, 50%). Interestingly, there were 2 MIC-to-MIC collaborations (2/18, 11.1%) as well as 1 MIC-to-LIC (1/18, 5.6%) and 1 LIC-to-LIC partnership. At the time of response, 6 (33.3%) of the matches had at least resulted in initial contact via email or telephone. One of the partnerships had involved face-to-face interaction via video conference. A total of 4 respondents had traveled internationally to visit their partner's institution.

Conclusions: Within its first year of launch, the InterSurgeon membership has grown significantly. The partnerships that have already been formed involve not only international visits between HICs and low- to middle-income countries (LMICs), but also telecollaboration and inter-LMIC connections that allow for greater exchange of knowledge and expertise. As membership and site features grow to include other surgical and anesthesia specialties, membership growth and utilization is expected to increase rapidly over time according to social network dynamics.
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http://dx.doi.org/10.3171/2019.12.FOCUS19859DOI Listing
March 2020

Corpus callosotomy for treatment of drug-resistant epilepsy: a review of 16 pediatric cases in northern Vietnam.

J Neurosurg Pediatr 2020 Feb 28:1-6. Epub 2020 Feb 28.

3Department of Neurosurgery, University of Alabama at Birmingham, Alabama; and.

Objective: The aim of this study was to evaluate postoperative seizure outcome in children with drug-resistant epilepsy not eligible for focal resection who underwent corpus callosotomy.

Methods: The study included 16 patients undergoing corpus callosotomy between September 2015 and May 2018. Seizure semiology and frequency, psychomotor status, and video electroencephalography and imaging findings were evaluated for all patients.

Results: Of the 16 patients who underwent callosotomy during the study period, 11 underwent complete callosotomy and 5 underwent anterior only. Seizure improvement greater than 75% was achieved in 37.5% of patients, and another 50% of patients had seizure improvement of 50%-75%. No sustained neurological deficits were observed in these patients. There were no significant complications. Duration of postoperative follow-up ranged from 12 to 44 months.

Conclusions: Corpus callosotomy is an effective treatment for selected patients with drug-resistant epilepsy not eligible for focal resection in resource-limited settings. Fostering and developing international epilepsy surgery centers should remain a high priority for the neurosurgical community at large.
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http://dx.doi.org/10.3171/2019.12.PEDS19638DOI Listing
February 2020

The growth of pediatric neurosurgery in southern Vietnam and the first separation of pygopagus twins: case report.

J Neurosurg Pediatr 2020 Jan 17:1-7. Epub 2020 Jan 17.

4Pediatric Surgery Department, Children's Hospital 2, Ho Chi Minh City.

Conjoined twins are a rare congenital abnormality with an estimated incidence of 1:50,000 pregnancies and 1:200,000 live births. Pygopagus twins are characterized by sacrococcygeal fusion that is commonly associated with perineal and spinal abnormalities. Management of this complex disease requires a well-developed surgical system with multidisciplinary capacity and expertise.A decade ago there were no dedicated pediatric neurosurgeons in southern Vietnam. This has changed within a few short years; there are now 10 dedicated pediatric neurosurgeons with continually expanding technical capacity. In August 2017 a multidisciplinary surgical and anesthetic team successfully separated female pygopagus twins with fused sacrum and spinal cord with associated myelomeningocele defect.The authors present here the first successful separation of pygopagus twins in Vietnam as a representative case of gradual and sustainable pediatric neurosurgical scale-up.
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http://dx.doi.org/10.3171/2019.11.PEDS19291DOI Listing
January 2020

In Reply: A Bibliometric Analysis of Neurosurgical Practice Guidelines.

Neurosurgery 2020 04;86(4):E405-E406

Department of Neurological Surgery The University of Alabama at Birmingham Birmingham, Alabama.

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http://dx.doi.org/10.1093/neuros/nyz539DOI Listing
April 2020

Incidence of delayed intracranial hypertension in children with isolated sagittal synostosis following open calvarial vault reconstruction.

Childs Nerv Syst 2020 03 5;36(3):545-550. Epub 2019 Dec 5.

Department of Neurosurgery, University of Alabama at Birmingham School of Medicine, 1057 Faculty Office Tower, 510 20th Street South, Birmingham, AL, 35294-3410, USA.

Purpose: Delayed intracranial hypertension (DIH) occurs most frequently in children with syndromic or multi-suture synostosis after surgical correction. The rarity of DIH in children with isolated non-syndromic sagittal synostosis (ISS) warrants follow-up evaluation by large craniofacial centers until skeletal maturity. This study reports the incidence of DIH in children following open repair for ISS by our center's craniofacial team.

Methods: A single-center retrospective study of patients who underwent open calvarial vault remodeling (CVR) for ISS at our institution between November 2000 and November 2012 was performed. Syndromic and multi-suture synostosis patients were excluded. Demographic and follow-up data were extracted from the medical record for analysis until July 2017.

Results: One hundred five patients with ISS were identified who had undergone CVR in the aforementioned timeframe. Average age at initial surgery was 11.7 ± 15.32 months. Mean follow-up in our craniofacial clinic was 4.94 ± 3.53 years, with 69 patients (65.7%) having follow-up in craniofacial clinic ≥ 3 years and 74 (70.5%) having follow-up ≥ 3 years in any clinic at our institution. Four patients (3.8%) had intracranial pressure (ICP) monitors placed for symptoms concerning for DIH, one of which (0.95%) had confirmed DIH and underwent a second surgical procedure at 7.4 years of age. The patient presented late initially, having his first operation at 1.56 years of age.

Conclusion: One patient out of 105 (0.95%) developed DIH, confirmed by ICP monitoring, and required reoperation. The occurrence of DIH, albeit rare, remains an important topic to include in parental discussions and mandates long-term follow-up in this population.
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http://dx.doi.org/10.1007/s00381-019-04406-7DOI Listing
March 2020

Comprehensive Policy Recommendations for Head and Spine Injury Care in Low- and Middle-Income Countries.

World Neurosurg 2019 Dec 19;132:434-436. Epub 2019 Nov 19.

Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.

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http://dx.doi.org/10.1016/j.wneu.2019.08.240DOI Listing
December 2019

Pediatric herniated lumbar disc: a population-based risk factor analysis.

J Neurosurg Pediatr 2019 Nov 29:1-8. Epub 2019 Nov 29.

Objective: Surgical treatment of herniated lumbar disc (HLD) remains rare in children. The purpose of this study was to evaluate for potential disease risk factors leading to surgery based on a large single-center experience.

Methods: Data for all patients who had undergone surgical treatment for HLD between December 2008 and December 2016 at a single pediatric tertiary care referral center were collected and compared to data for a healthy control population obtained through a Youth Risk Behavior Surveillance System (YRBSS) survey in order to determine relevant disease risk factors. Univariate and multivariate logistic regression were used to determine the effect of potential risk factors.

Results: Twenty-seven patients in the disease cohort and 5212 healthy controls from the general population were included in the risk factor analysis. The mean body mass index was significantly higher in the disease population (30.2 vs 24.0 kg/m2, p < 0.0001). Children who had undergone microdiscectomy were more likely to be obese (OR 7.4, 95% CI 3.46-15.8, p < 0.001). No association was found between lumbar microdiscectomy and sports participation (OR 1.0, 95% CI -0.002 to 0.005, p = 0.37).

Conclusions: Microdiscectomy remains a viable and safe option in the setting of failed conservative management for pediatric HLD. Childhood obesity is a risk factor for HLD and many other diseases, which increases its importance as a public health priority.
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http://dx.doi.org/10.3171/2019.9.PEDS19167DOI Listing
November 2019

Interrater and Intrarater Reliability of the Colloid Cyst Risk Score.

Neurosurgery 2020 01;86(1):E47-E53

Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama.

Background: The Colloid Cyst Risk Score (CCRS) was developed to identify symptomatic patients and stratify risk of hydrocephalus among patients with colloid cysts. Its components consider patient age, cyst diameter, presence/absence of headache, fluid-attenuated inversion recovery (FLAIR) hyperintensity, and location within the third ventricle.

Objective: To independently evaluate the inter- and intrarater reliability of the CCRS.

Methods: Patients with a colloid cyst were identified from billing records and radiology archives. Three independent raters reviewed electronic medical records to determine age, presence/absence of headache, cyst diameter (mm), FLAIR hyperintensity, and risk zone location. Raters made 53 observations, including 5 repeat observations.Fleiss' generalized kappa (κ) was calculated for all of the nominal criteria, whereas Kendall's coefficient of concordance (W) and the intraclass correlation coefficient (ICC) were calculated for the overall score.

Results: Total CCRS score demonstrated extremely strong agreement (W = 0.83) using Kendall's W coefficient and good agreement (ICC = 0.74) using the ICC (P < .001). For interrater reliability of individual criteria, age (κ = 1.00) and FLAIR hyperintensity (κ = 0.89) demonstrated near perfect agreement. Axial diameter (κ = 0.63) demonstrated substantial agreement, whereas agreement was moderate for risk zone (κ = 0.51) and fair for headache (κ = 0.26). Intrarater reliability for total CCRS score was extremely strong using Kendall's W, good to excellent using ICC, and fair to substantial using weighted kappa.

Conclusion: The CCRS has good inter- and intrarater reliability when tested in an independent sample of patients, though strength of agreement varies among individual criteria. The validity of the CCRS requires independent evaluation.
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http://dx.doi.org/10.1093/neuros/nyz399DOI Listing
January 2020

A Bibliometric Analysis of Neurosurgical Practice Guidelines.

Neurosurgery 2020 05;86(5):605-614

Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama.

Background: In the last 20 yr, the rate of neurosurgical guideline publication has increased. However, despite the higher volume and increasing emphasis on quality there remains no reliable means of measuring the overall impact of clinical practice guidelines (CPGs).

Objective: To utilize citation analysis to evaluate the dispersion of neurosurgical CPGs.

Methods: A list of neurosurgical guidelines was compiled by performing electronic searches using the Scopus (Elsevier, Amsterdam, Netherlands) and National Guideline Clearinghouse databases. The Scopus database was queried to obtain current publication and citation data for all included documents and categorized based upon recognized neurosurgical specialties. The h-index, R-index, h2-index, i10-index, and dissemination index (D-Index) were manually calculated for each subspecialty.

Results: After applying screening criteria the search yielded 372 neurosurgical CPGs, which were included for bibliometric analysis. The overall calculated h-index for neurosurgery was 56. When broken down by subspecialty trauma/critical care had the highest value at 35, followed by spine and peripheral nerve at 30, cerebrovascular at 28, tumor at 16, pediatrics at 14, miscellaneous at 11, and functional/stereotactic/pain at 6. Cerebrovascular neurosurgery was noted to have the highest D-Index at 3.4.

Conclusion: A comprehensive framework is useful for guideline impact analysis. Bibliometric data provides a novel and adequate means of evaluating the successful dissemination of neurosurgical guidelines. There remains a paucity of data regarding implementation and clinical outcomes of individual guidelines.
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http://dx.doi.org/10.1093/neuros/nyz240DOI Listing
May 2020

Postgraduate publishing output in pediatric neurosurgery: correlation with fellowship site and individual scholars.

J Neurosurg Pediatr 2019 Jun 21:1-9. Epub 2019 Jun 21.

3Department of Neurosurgery, The University of Tennessee Health Science Center, Memphis, Tennessee.

Objective: The objective of this study was to analyze the publication output of postgraduate pediatric neurosurgery fellows for a 10-year period as well as identify 25 individual highly productive pediatric neurosurgeons. The correlation between academic productivity and the site of fellowship training was studied.

Methods: Programs certified by the Accreditation Council for Pediatric Neurosurgery Fellowships that had 5 or more graduating fellows from 2006 to 2015 were included for analysis. Fellows were queried using Scopus for publications during those 10 years with citation data through 2017. Pearson correlation coefficients were calculated, comparing program rankings of faculty against fellows using the revised Hirsch index (r-index; primary) and Hirsch index (h-index; secondary). A list of 25 highly accomplished individual academicians and their fellowship training locations was compiled.

Results: Sixteen programs qualified with 152 fellows from 2006 to 2015; 136 of these surgeons published a total of 2009 articles with 23,735 citations. Most publications were pediatric-specific (66.7%) clinical articles (93.1%), with middle authorship (55%). Co-investigators were more likely from residency than fellowship. There was a clustering of the top 7 programs each having total publications of around 120 or greater, publications per fellow greater than 12, more than 1200 citations, and adjusted ir10 (revised 10-year institutional h-index) and ih10 (10-year institutional h-index) values of approximately 2 or higher. Correlating faculty and fellowship program rankings yielded correlation coefficients ranging from 0.53 to 0.80. Fifteen individuals (60%) in the top 25 (by r5 index) list completed their fellowship at 1 of these 7 institutions.

Conclusions: Approximately 90% of fellowship-trained pediatric neurosurgeons have 1 or more publications, but the spectrum of output is broad. There is a strong correlation between where surgeons complete their fellowships and postgraduate publications.
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http://dx.doi.org/10.3171/2019.4.PEDS18717DOI Listing
June 2019
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