Background: Residency training is well-known to be an arduous life event - especially in neurosurgery. The Maslach Burnout Index (MBI) is the gold standard for assessing burnout while the Perceived Stress Scale (PSS) identifies the relative importance of stressors. The purpose of this study is to quantify resident wellness using two validated instruments (MBI and PSS). Methods: The MBI and PSS were anonymously administered to all residents. Scores were compiled and analyzed. Freeform data was collected to identify areas for intervention. Results: Completion rate was 8/9 residents. Baseline scores showed 71% had at least moderately low personal accomplishment, 86% at least moderate emotional exhaustion, and 71% at least moderate depersonalization. 86% had above average perceived stress. Areas for improvement included call room conditions, increased social events, and study resource funding. Conclusions: Most residents are objectively experiencing low personal accomplishment, above average emotional exhaustion and depersonalization, and above average perceived stress. Assessments will characterize temporal trends, identify avenues for wellness improvement, and be correlated with interventions.

Background: Infundibular lesions are rare entities with variable clinical manifestations. Their detection during workup for endocrinologic abnormalities represents a decision-making challenge. We present a patient with ACTH-dependent hypercortisolemia found to have a stalk lesion, which was treated surgically. Methods: Information was gathered from electronic medical records. Results: A 57F underwent workup for Cushing’s syndrome, demonstrating evidence of ACTH-dependent hypercortisolemia. Imaging demonstrated a 4.7mm infundibular nodule. We elected to proceed with endoscopic endonasal approach for resection of the infundibular lesion with goal of biochemical cure. A satisfactory technical and radiographic resection of the infundibular lesion was achieved. However, the patient’s hypercortisolemia failed to resolve. Histopathologic analysis identified the lesion as a granulocytoma. Inferior petrosal sinus sampling further demonstrated evidence of ACTH-dependent central hypercortisolemia. She then underwent bilateral adrenalectomy for management of her persistent hypercortisolemia. Conclusions: This demonstrates a complex clinical picture in which our patient presented with biochemical results suggesting central ACTH-dependent hypercortisolemia with no identifiable glandular lesion. The presence of an infundibular lesion led to surgical intervention which unfortunately did not result in biochemical cure despite adequate technical results. The authors believe this case illustrates a challenging clinical conundrum which emphasizes the uncertainty that should be associated with management of stalk lesions.

Background: Leadership drives innovation, patient care and resident education in neurosurgery. This study aims to quantitatively analyze the demographic and professional characteristics of leaders in Canadian academic neurosurgery. Methods: Leaders in remunerated positions, such as department chairs and program directors, from the 14 Canadian Royal College of Physicians and Surgeons-accredited neurosurgery programs were identified using publicly available online resources, chain-referral sampling, and personal communications. Demographic and professional data were collected and analyzed using frequency analyses and exploratory chi-square tests. Results: Thirty-four neurosurgical leaders were identified, predominantly in Québec (29.4%) and Ontario (26.5%). Pediatrics (26.5%) was the most common subspecialty. Over half of leaders held positions in the institution where they trained (52.9%). Among non-Quebec programs, male neurosurgeons were less likely than females to hold leadership positions (p = 0.040, OR = 0.344, 95% CI 0.12-0.99), although males still predominated (18 males vs. 6 females). In Quebec, no gender association was found (p = 0.652). Leaders averaged 76.4 (±81.49) publications and an h-index of 19.71 (±15.12) with nearly two-thirds holding advanced degrees. Conclusions: This study establishes the current landscape of leaders in Canadian academic neurosurgery. Further research is needed to explore career trajectory and barriers to leadership in the field.

Background: Treatment for sagittal craniosynostosis often involves endoscopic suturectomy (ES) followed by helmet therapy, with cranial shape improvement assessed via cephalic index (CI). The effect of adding barrel-stave osteotomy (BSO) to ES on CI outcomes remains controversial. This study evaluated the impact of BSO on operative burden and postoperative cranial deformity in patients undergoing surgical correction of sagittal craniosynostosis. Methods: A retrospective review of 85 patients treated for sagittal craniosynostosis at BC Children’s Hospital (2010–2021) compared patients undergoing ES alone (n=18) and ES+BSO (n=67). Demographics, operative burden (anesthesia and surgical time, blood loss, hospital stay), and longitudinal CI measurements were analyzed. Mixed effects modeling controlled for age, preoperative CI, and helmet duration. Results: Operative burden did not differ significantly between treatment groups (p > 0.05). The median follow-up duration for CI measurements was 56.0 months. While preoperative CI was similar (67.4 vs. 66.8, p=0.61), CI was significantly improved in the ES+BSO group at all postoperative intervals (p ≤ 0.02). Mixed effects modeling confirmed that BSO independently improved CI (effect size 2.21, p=0.001). Conclusions: In our series, the addition of BSO to ES significantly improved immediate and long-term cranial deformity without increasing operative burden, supporting its use in sagittal craniosynostosis correction.

Background: Treatment-resistant obsessive compulsive disorder (trOCD) is a condition characterized by intrusive thoughts (obsessions) and uncontrollable behaviours (compulsions) unresponsive to conventional therapies. Lesioning both anterior limbs of the internal capsule is effective in ablating the circuitry underlying trOCD pathophysiology. The newest capsulotomy method is MR-guided focused ultrasound (MRgFUS). Here we measured neural networks changes of trOCD patients after MRgFUS capsulotomy using resting state functional MRI (rs-fMRI). Methods: Yale-Brown Obsessive-Compulsive Scale (YBOCS) scores and rs-fMRI data were collected in 6 trOCD patients preoperatively, postoperatively at 3-months and 1-year, along with rs-fMRI from 6 age and sex-matched controls. Independent component analysis, dual regression using the FMRIB software library, and node-node approaches were used with the CONN Toolbox. We also performed a systematic review of existing studies about trOCD resting state networks. Results: TrOCD patients demonstrated significant improvement 1-year postoperatively (mean YBOCS reduction of 41 ± 7%). Dual regression analysis 3-months postoperatively showed significantly greater sensorimotor network signal in controls compared to trOCD groups. Node-node analysis in trOCD found connectivity changed in networks associated with the cortico-striato-thalamo-cortico loop, particularly the salience and limbic networks at 1-year postoperatively. Conclusions: TrOCD patients who underwent MRgFUS capsulotomy demonstrated differences in sensorimotor and cortico-striatal connectivity and significant clinical improvement postoperatively.

Background: Arachnoid cysts are fluid collections within the arachnoid membrane. Although rare, ruptured or hemorrhagic arachnoid cysts pose significant clinical challenges and management controversies. The present study analyzes factors influencing their treatment decision using Bayesian network models. Methods: PubMed and EMBASE databases were searched to identify reports of ruptured arachnoid cysts with patient-level data. Demographic, clinical, imaging and treatment data were extracted to develop Tree-augmented naïve Bayes (TAN) classifiers for analyzing the factors influencing decision of surgery and type of surgery. A web application was developed to explore the networks. Results: Middle cranial fossa cysts were most common (95%) along with a male predominance (M:F ratio 4.29:1). Headache and vision changes were the most common symptoms and >50% had a history of head injury. Surgery was performed in 89.8% of cases with craniotomy being the most common surgical procedure. Key factors influencing the decision of surgery were cyst location, hemorrhage type, age group, and Galassi classification, while type of surgery was also influenced by head trauma, seizures, and macrocrania. Conclusions: Bayesian network analysis demonstrates that decision of surgical treatment of a ruptured arachnoid cyst is dependent on multiple interdependent factors and should be individualized to match the presentation with the surgical modality.

Background: Recent research has identified the coexistence of normal pressure hydrocephalus (NPH) with neurodegenerative disorders, such as progressive supranuclear palsy (PSP). We present a patient with shunt-responsive NPH that was diagnosed with PSP at autopsy, in the absence of the typical clinical features of PSP antemortem. Methods: Medical records were reviewed, including diagnostic imaging and neuropathology. A literature review was conducted. Results: A 78-year-old female presented with a 4-year history of progressive gait dysfunction and cognitive impairment. MRI imaging was consistent with NPH. The patient’s clinical status improved significantly following high-volume lumbar puncture, with TUG test results decreasing to 25.19 sec from 58.73 sec. A lumboperitoneal shunt was inserted. Subsequent clinical improvement was impermanent, despite the absence of shunt malfunction. Autopsy revealed neuropathological findings consistent with PSP. We have identified 7 similar cases of NPH patients found to have concomitant PSP at autopsy in the literature. Like the case we present, these shunted patients experienced an initial, but unsustained, improvement in clinical status. Conclusions: We recommend the clinical management of NPH patients includesurveillance for neurodegenerative disorders. CSF diversion in NPH patients who develop concomitant PSP benefit from CSF diversion, offering them an interval of significantly improved quality of life.

Background: Subdural hematoma (SDH) is a serious complication of shunt surgery for normal pressure hydrocephalus (NPH). Since the introduction of adjustable valves, management strategy has changed significantly. Methods: A retrospective review of NPH patients treated in the Hydrocephalus and CSF Disorders Clinic over the past five years was conducted. A review of clinical materials and imaging identified 32 patients who developed SDH following shunt surgery for NPH. Results: Twenty-seven patients were male and five were female. Mean age was 74. All patients received programmable valves. Nineteen patients were diagnosed with SDH within six months of shunt insertion, with a mean duration to diagnosis of 48 days. Five required surgery. The remaining 14 patients were treated successfully with shunt adjustment. All patients returned to their clinical baseline. Thirteen of the 32 patients developed SDH after a period of six months, with a mean duration to diagnosis of 43 months. None required surgical intervention. Ten patients were treated with shunt adjustment. The remainder were observed. Conclusions: Close surveillance following shunt insertion, particularly within the first six months post-op, is essential to prevent significant clinical sequelae secondary to SDH. Programmable valves can play an important role in early SDH management.

Background: Degenerative Cervical Myelopathy (DCM) is a progressive condition causing cervical spinal cord injury. Disease severity is commonly assessed using the modified Japanese Orthopedic Association (mJOA) score, yet clinical guidelines do not integrate pain—a key symptom—in evaluations. This meta-analysis examines the relationship between pain scores and quality of life outcomes (QOL) in surgical DCM patients. Methods: A comprehensive literature search using MEDLINE, Web of Science, and Embase identified 73 studies. Data regarding pain scores (VAS/NRS) and QOL outcomes (SF-12, SF-36) were extracted by 2 independent reviewers and all conflicts were resolved by the senior author. The number of patients analyzed in the studies included was 929. Results: Meta-regression identified no significant relationship between pain and SF-36 preoperatively but found a significant negative correlation at 3 months (r = -0.67, p<0.05), 6 months (r = -0.65, p<0.05), 1 year (-0.63, p<0.05), and 2 years (r = -0.62, p<0.05). Conclusions: Our results indicate a strong relationship between postoperative pain and QOL among patients with DCM. Surgeons and care teams should prioritize optimal pain management postoperatively for patients with DCM.

Background: Dural tears (DT) are relatively common spine surgery complications, increasing risks of cerebrospinal fluid leaks, adverse events, and prolonged hospitalization. This study sought to identify DT predictors and compare postoperative outcomes including adverse events, revision, emergency room (ER) care, and length of stay between DT and non-DT cohorts. Methods: Retrospective analysis of elective spine surgery patients at a single tertiary centre. Variables included demographics, DT repair techniques, risk factors, post-operative adverse events, ER care within 30 days post-op, and revision. Binary logistic regression was used to analyze risk factors while hierarchical logistic and linear regressions analyzed postoperative events. Results: 6.6% of patients experienced DTs, with patches used in 40% of repairs. Age was a risk factor for DT (EXP(B)=1.039, CI [1.016, 1.063]), while minimally invasive surgery (MIS) (EXP(B)=0.521, CI [.297, .912]) reduced risk. DTs were associated with increased rates of cardiac arrest (EXP(B) = 3.966, CI [1.046, 15.033]), urinary retention (EXP(B)=2.408, CI [1.218, 4.759]), revision (EXP(B)=4.574, CI [1.941, 10.779]), ER visits (EXP(B)=1.975, CI [1.020, 3.826]), and length of stay (B=3.42, p<0.001). Conclusions: MIS seems to be associated with decreased DT risk. DTs are also associated with post-operative cardiac arrest, urinary retention, required revision surgery, and visits to the ER within 30 days post-op.

Background: Endonasal endoscopic odontoidectomy (EEO) is a well-established method for treating symptomatic ventral compression at the cranio-cervical junction (CCJ). This study aims to review the clinical outcomes of patients undergoing EEO, focusing on clinical presentation, progression, and prognostic factors. Methods: We retrospectively analyzed data from patients who underwent EEO between October 2001 and October 2023. Information was collected on demographics, indications, reconstruction techniques, complications, fusion requirements, readmission rates, and outcomes. Results: Fifteen patients were included, with 60% classified as ASA class III. The majority presented with myelopathy (80%). Indications for surgery included basilar invagination, Chiari malformation, and rheumatoid arthritis. The mean blood loss was 317 ml. No perioperative lumbar drains were used, and 26.7% of patients had intraoperative CSF leaks, though no postoperative leaks were noted. A pedicled nasal flap was required in 66.7% of cases. Fourteen patients needed occipitocervical fusion, and six were readmitted within 30 days due to bulbar deficits. At the last follow-up, 86.6% of patients experienced symptom improvement. A significant association was found between decompression extent and symptomatic improvement (p=0.003). Conclusions: EEO is a safe and effective method for CCJ decompression, often accompanied by posterior cervical stabilization, with most patients showing symptomatic improvement and a low complication rate.

Background: Surgical robotics can minimize the discrepancy between surgical preoperative plan and postoperative execution. This work explores the performance of a supervisory-control architecture robot (8i Robotics) for autonomous pedicle instrumentation in both an open and MIS workflow in a poricne model, as well as guidance accuracy in humans. Methods: 11 porcine subjects (7 open, 4 minimally invasive) had clinical grading assessment of pedicle screw placement. 3 of the open cohort had detailed precision analysis. Post-operative CT assessed screw location. Euclidean error was calculated at screw head and screw tip and confidence ellipses generated. In two human patients, guidance accuracy was compared to existing neuro-navigation. Results: All screws where GRS A. There was no clinical difference between clinical assessment of MIS vs Open workflow. Mean tip and head Euclidean error where 2.47+/-1.25mm and 2.25+/-1.25mm respectively. Guidance was successfully obtained in both human cases. Conclusions: 100% of screws obtained satisfactory clinical grading. This demonstrates the capability of a supervisory controlled robotic pedicle screw insertion robot in both open and minimally invasive workflow. Furthermore, initial guidance was feasible in living human patients with comparable agreement to current navigation. This work demonstrates exciting promise for the future of autonomous surgical robotics.