Catherine A. Mazzola

Efficacy of neurosurgery resident education in the new millennium: the 2008 Council of State Neurosurgical Societies post-residency survey results.

BACKGROUNDNeurosurgical residency training paradigms have changed in response to Accreditation Council for Graduate Medical Education mandates and demands for quality patient care. Little has been done to assess resident education from the perspective of readiness to practice. OBJECTIVETo assess the efficacy of resident training in preparing young neurosurgeons for practice. METHODSIn response to Resolution V-2007F of the Council of State Neurosurgical Societies, a survey was developed for neurosurgeons who applied for oral examination, Part II of the American Board of Neurological Surgery boards, in 2002 through 2007 (N = 800). The survey was constructed in “survey monkey” format and sent to 775 of 800 (97%) neurosurgeons for whom e-mail addresses were available. RESULTSThe response rate was 30% (233/775). Most neurosurgeons were board certified (n = 226, 97%). General neurosurgical training was judged as adequate by a large majority (n = 188, 80%). Sixty-percent chose to pursue at least 1 additional year of fellowship training (n = 138, 60%). Surgical skills training was acceptable, but 6 skill-technique areas were reported to be inadequate (endovascular techniques, neurosurgical treatment of pain, stereotactic radiosurgery, epilepsy surgery, cranial base surgery, and stereotactic neurosurgery). Respondents also noted inadequate education in contract negotiation, practice evaluation, and management. CONCLUSIONThe study suggests that neurosurgeons believed that they were well trained in their surgical skills except for some areas of subspecialization. However, there is a significant need for improvement of resident training in the areas of socioeconomic and medicolegal education. Continued evaluation of the efficacy of neurosurgical education is important.

Pediatric hydrocephalus: systematic literature review and evidence-based guidelines. Part 8: Management of cerebrospinal fluid shunt infection

OBJECT The objective of this systematic review was to answer the following question: What is the optimal treatment strategy for CSF shunt infection in pediatric patients with hydrocephalus? METHODS The US National Library of Medicine and the Cochrane Database of Systematic Reviews were queried using MeSH headings and key words relevant to the objective of this systematic review. Abstracts were reviewed, after which studies meeting the inclusion criteria were selected and graded according to their quality of evidence (Classes I-III). Evidentiary tables were constructed that summarized pertinent study results, and based on the quality of the literature, recommendations were made (Levels I-III). RESULTS A review and critical appraisal of 27 studies that met the inclusion criteria allowed for a recommendation for supplementation of antibiotic treatment using partial (externalization) or complete shunt hardware removal, with a moderate degree of clinical certainty. However, a recommendation regarding whether complete shunt removal is favored over partial shunt removal (that is, externalization) could not be made owing to severe methodological deficiencies in the existing literature. There is insufficient evidence to recommend the use of intrathecal antibiotic therapy as an adjunct to systemic antibiotic therapy in the management of routine CSF shunt infections. This also holds true for other clinical scenarios such as when an infected CSF shunt cannot be completely removed, when a shunt must be removed and immediately replaced in the face of ongoing CSF infection, or when the setting is ventricular shunt infection caused by specific organisms (for example, gram-negative bacteria). CONCLUSIONS Supplementation of antibiotic treatment with partial (externalization) or complete shunt hardware removal are options in the management of CSF shunt infection. There is insufficient evidence to recommend either shunt externalization or complete shunt removal as the preferred surgical strategy for the management of CSF shunt infection. Therefore, clinical judgment is required. In addition, there is insufficient evidence to recommend the combination of intrathecal and systemic antibiotics for patients with CSF shunt infection when the infected shunt hardware cannot be fully removed, when the shunt must be removed and immediately replaced, or when the CSF shunt infection is caused by specific organisms. The potential neurotoxicity of intrathecal antibiotic therapy may limit its routine use. RECOMMENDATION Supplementation of antibiotic treatment with partial (externalization) or with complete shunt hardware removal is an option in the management of CSF shunt infection. STRENGTH OF RECOMMENDATION Level II, moderate degree of clinical certainty. RECOMMENDATION There is insufficient evidence to recommend either shunt externalization or complete shunt removal as a preferred surgical strategy for the management of CSF shunt infection. Therefore, clinical judgment is required. STRENGTH OF RECOMMENDATION Level III, unclear degree of clinical certainty. RECOMMENDATION There is insufficient evidence to recommend the combination of intrathecal and systemic antibiotics for patients with CSF shunt infection in whom the infected shunt hardware cannot be fully removed or must be removed and immediately replaced, or when the CSF shunt infection is caused by specific organisms. The potential neurotoxicity of intrathecal antibiotic therapy may limit its routine use. STRENGTH OF RECOMMENDATION Level III, unclear degree of clinical certainty.

Pediatric hydrocephalus: systematic literature review and evidence-based guidelines. Part 5: Effect of valve type on cerebrospinal fluid shunt efficacy.

OBJECT The objective of this systematic review was to examine the existing literature to compare differing shunt components used to treat hydrocephalus in children, find whether there is a superior shunt design for the treatment of pediatric hydrocephalus, and make evidence-based recommendations for the selection of shunt implants when placing shunts. METHODS Both the US National Library of Medicine PubMed/MEDLINE database and the Cochrane Database of Systematic Reviews were queried using MeSH headings and key words chosen to identify publications comparing the use of shunt implant components. Abstracts of these publications were reviewed, after which studies meeting the inclusion criteria were selected. An evidentiary table was compiled summarizing the selected articles and quality of evidence. These data were then analyzed by the Pediatric Hydrocephalus Systematic Review and Evidence-Based Guidelines Task Force to consider evidence-based treatment recommendations. RESULTS Two hundred sixty-nine articles were identified using the search parameters, and 43 articles were recalled for full-text review. Of these, 22 papers met the study criteria for a comparison of shunt components and were included in the evidentiary table. The included studies consisted of 1 Class I study, 11 Class II studies, and 10 Class III studies. The remaining 21 articles were excluded. CONCLUSIONS An analysis of the evidence did not demonstrate a clear advantage for any specific shunt component, mechanism, or valve design over another. RECOMMENDATION There is insufficient evidence to demonstrate an advantage for one shunt hardware design over another in the treatment of pediatric hydrocephalus. Current designs described in the evidentiary tables are all treatment options. STRENGTH OF RECOMMENDATION Level I, high degree of clinical certainty. RECOMMENDATION There is insufficient evidence to recommend the use of a programmable valve versus a nonprogrammable valve. Programmable and nonprogrammable valves are both options for the treatment of pediatric hydrocephalus. STRENGTH OF RECOMMENDATION Level II, moderate degree of clinical certainty.

Pediatric hydrocephalus: systematic literature review and evidence-based guidelines. Part 10: Change in ventricle size as a measurement of effective treatment of hydrocephalus

OBJECT The objective of this systematic review is to answer the following question: Does ventricle size after treatment have a predictive value in determining the effectiveness of surgical intervention in pediatric hydrocephalus? METHODS The US National Library of Medicine PubMed/MEDLINE database and the Cochrane Database of Systematic Reviews were searched using MeSH headings and key words relevant to change in ventricle size after surgical intervention for hydrocephalus in children. An evidentiary table was assembled summarizing the studies and the quality of evidence (Classes I-III). RESULTS Six articles satisfied inclusion criteria for the evidentiary tables for this part of the guidelines. All were Class III retrospective studies. CONCLUSIONS/RECOMMENDATIon: There is insufficient evidence to recommend a specific change in ventricle size as a measurement of the effective treatment of hydrocephalus and as a measurement of the timing and effectiveness of treatments including ventriculoperitoneal shunts and third ventriculostomies. STRENGTH OF RECOMMENDATION Level III, unclear clinical certainty.

Guidelines: Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline for the Diagnosis of Patients with Positional Plagiocephaly: The Role of Imaging

BACKGROUND No evidence-based guidelines exist for the imaging of patients with positional plagiocephaly. OBJECTIVE The objective of this systematic review and evidence-based guideline is to answer the question, Is imaging necessary for infants with positional plagiocephaly to make a diagnosis? METHODS The National Library of Medicine Medline database and the Cochrane Library were queried with the use of MeSH headings and key words relevant to imaging as a means to diagnose plagiocephaly. Abstracts were reviewed, and an evidentiary table was assembled summarizing the studies and the quality of evidence (Classes I-III). Based on the quality of the literature, a recommendation was rendered (Level I, II, or III). RESULTS A total of 42 full-text articles were selected for review. Of these, 10 were eliminated; thus, 32 full-text were manuscripts selected. There was no Class I evidence, but 2 Class II and 30 Class III studies were included. Three-dimensional cranial topographical imaging, ultrasound, skull x-rays, computed tomography, and magnetic resonance imaging were investigated. CONCLUSION Clinical examination is most often sufficient to diagnose plagiocephaly (quality, Class III; strength, Level III). Within the limits of this systematic review, the evidence suggests that imaging is rarely necessary and should be reserved for cases in which the clinical examination is equivocal. Many of the imaging studies were not designed to address the diagnostic utility of the imaging modality, and authors were actually assessing the utility of the imaging in longitudinal follow-up, not initial diagnosis. For this reason, some of the studies reviewed were downgraded in Level of Evidence. When needed, 3-dimensional cranial topographical photo, skull x-rays, or ultrasound imaging is almost always sufficient for definitive diagnosis. Computed tomography scanning should not be used to diagnose plagiocephaly, but it may be necessary to rule out craniosynostosis. The full guidelines document can be located at https://www.cns.org/guidelines/guidelines-management-patients-positional-plagiocephaly/Chapter_2.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines for the Management of Patients with Positional Plagiocephaly: Executive Summary

BACKGROUND Positional plagiocephaly is a common problem seen by pediatricians, pediatric neurologists, and pediatric neurosurgeons. OBJECTIVE To create evidence-based guidelines for the treatment of pediatric positional plagiocephaly. METHODS This guideline was prepared by the Plagiocephaly Guideline Task Force, a multidisciplinary team made up of physician volunteers (clinical experts), medical librarians, and clinical guidelines specialists. The task force conducted a series of systematic literature searches of PubMed and the Cochrane Library, according to standard protocols for each topic addressed in subsequent chapters of this guideline. RESULTS The systematic literature searches returned 396 abstracts relative to the 4 main topics addressed in this guideline. The results were analyzed and are described in detail in each subsequent chapter included in this guideline. CONCLUSION Evidence-based guidelines for the management of infants with positional plagiocephaly will help practitioners manage this common disorder. The full guidelines documents can be located at https://www.cns.org/guidelines/guidelines-management-patients-positional-plagiocephaly.

Benefits of Temporary Intrathecal Baclofen Therapy: Management of Tone and Spasticity

Background: Our objectives are to report the efficacy and safety of intrathecal baclofen (ITB) therapy for the temporary treatment of spasticity and dystonia, and to illustrate the benefit of temporary ITB therapy while patients are in rehabilitation. Methods: This is a retrospective case series of three patients with spasticity and dystonia who were treated with ITB. All patients had their pump and catheter explanted after their movement disorder resolved and their abilities improved, and they were slowly weaned off ITB. Results: ITB therapy prevented the development of complications related to inadequately treated spasticity and dystonia. All patients improved clinically to the extent where the ITB could be tapered off and discontinued. Each patient had their pump and catheter hardware explanted successfully. Conclusions: ITB therapy is effective in decreasing complications associated with hypertonicity and spastic dystonia. Removal of hardware is feasible for patients with clinical improvement after careful, decreasing titration of baclofen thereby avoiding withdrawal symptoms.