Background: Diversity of healthcare personnel has been associated with improved care of diverse populations. To determine whether neurosurgical clinical trialists were as diverse as the populations they treated, we investigated the sex/gender and race/ethnicity of participants and compared them to authors of randomized controlled trials (RCTs) in neurosurgery, orthopedic surgery, general surgery and plastic surgery. Methods: Embase and MEDLINE were systematically searched from 2001 to 2021. RCTs were limited by impact factor and selected using a series technique. Data on author and trial characteristics were extracted independently and in duplicate, and compared for each speciality. Results: 1548 articles were included. Interim analysis revealed the mean proportion of women authors was lowest in neurosurgery (5%) and highest in plastic surgery (50%). Trialists that were most reflective of their participants sex/gender were general surgery (42% authors vs 46% participants) and plastic surgery (50% authors vs 66% participants). 94% of RCTs did not report participants’ race/ethnicity. No RCTs excluded participants based on sex/gender or race/ethnicity. Conclusions: Compared to other surgical fields, neurosurgery had the poorest correlation of author sex/gender with the population being studied. Efforts are needed to improve the diversity of neurosurgical trialists, access to RCTs for underrepresented groups and standardized reporting of participants’ race/ethnicity.

Background: Endoscopic third ventriculostomy (ETV) is a successful procedure for treating noncommunicating hydrocephalus as an alternative to initial ventriculoperitoneal (VP) shunt placement and as a salvage procedure when a VP shunt fails. Physiological changes of pregnancy can lead to VP shunt failure and complicate the management of shunt malfunction, particularly in the third trimester. Methods: Case report: ETV was successfully used in the third trimester (31 weeks of gestation) of pregnancy for acute hydrocephalus due to VP shunt malfunction, and the patient went on to deliver a healthy baby at term; the patient remained well in the long-term follow-up. An English-language PubMed literature review revealed four cases of VP shunt failure successfully treated with an ETV in the first or second trimester but no such reports in the third trimester of pregnancy. Results: This case report adds to the sparse literature regarding the use of an ETV to treat VP shunt malfunction in the third trimester of pregnancy. This appears to be a unique first-time report of the use of an ETV during this specific challenging prenatal period. Conclusions: ETV appears to be a safe and effective alternative to VP shunt replacement in the late prenatal period of pregnancy in well-selected candidates.

Background: Dr. Penfield was a pioneer in neurosurgery and his contribution continues to impact the practice today. Our objective is to analyze the epilepsy surgeries during his career. Methods: Analysis of original operating room books from 1934-1960. Results: He performed 2338 procedures during his career. 601 (26%) epilepsy, 524 (22%) oncology, 441 (19%) general neurosurgery, 379 (16%) functional, 230 (10%) spine, 80 (3%) trauma, 54 (2%) vascular, 29 (1%) nerves.

Epilepsy cases were divided: local vs. general anesthesia and a focal resection or lobectomy. From 1934-1945 he performed 167 procedures, 146 local anesthesia with focal resection. From 1946-1950 223 procedures, introduction of lobectomies with 30. Most right-side procedures under general anesthesia. From 1951-1955 152 procedures, 88 focal resection, 64 lobectomies. From 1956-1960 59 surgeries, similar number of focal resection and lobectomies. Conclusions: To our knowledge this is the most complete and comprehensive account his surgical career. In early years patients were treated through large craniotomies with EEG stimulation to tailor focal resections now known as the “Montreal procedure”. This led to a better understanding of human cortex and the division of the brain functions. During later years, there was a reduction in the number of cases done under local anesthesia and increase in lobectomies.

Background: There is no objective way to measure the amount of manipulation and retraction of neural tissue by the surgeon. Our objective is to develop metrics quantifying dynamic retraction of cerebral tissue and the manipulation of instruments during a neurosurgical intervention. Methods: We trained a convolutional neural network to analyze microscopic footage of neurosurgical procedures and thereby generate metrics evaluating the surgeon’s dynamic retraction of brain tissue and the surgeon’s manipulation of the instruments themselves. U-Net image segmentation is used to output bounding polygons around cerebral parenchyma of interest, as well as the vascular structures and cranial nerves. Results: On the validation set, our network achieves a state of the art Intersection over Union (IoU) of 70.1% (Recall = 89%) and 74.3% (Recall = 91%) for surgical tools and biological structures respectively. Multivariate statistical analysis was used to evaluate dynamic retraction and tissue handling. Conclusions: We describe a semantic segmentation model for surgical instruments and intracranial structures to evaluate dynamic retraction of soft tissue and manipulation of instruments during a surgical procedure, while accounting for movement of the operative microscope. Using the intraoperative footage, this model can potentially provide the surgeon with objective feedback.

Background: Until recently, no effective treatment was available for spinal muscular atrophy (SMA). In 2017, Health Canada approved intrathecal Nusinersen a medication that prevents degeneration of the motor neurons in the spinal cord. The administration is intrathecally most commonly via lumbar puncture (LP) to have a direct effect on the motor neurons of the spinal cord.

Many older patients with SMA and concomitant spinal deformities present technical challenges to access the thecal sac. Different routes have been described for delivery of the medication. These techniques may require sedation, are associated with radiation exposure, and demand experience personnel. Methods: A new surgical technique has been proposed to overcome these obstacles by combining two Health Canada approved devices: 1) an intrathecal catheter designed for intrathecal baclofen pumps and 2) an implantable subcutaneous port designed for intravascular medication administration Results: We describe the technical nuances and outline the clinical outcomes of six patients with complex spine deformities who have undergone such an implant for administration of Nusinersen. Conclusions: We discuss the benefits of the procedure which includes: 1) administration in the outpatient setting without sedation, 2) avoidance of costly imaging and experienced personnel, and 3) placement of the catheter in the cervicothoracic junction.

Background: Intracranial capillary hemangiomas are rare, particularly in adults, and diagnosis can be challenging. The literature lacks visualization of intracranial capillary hemangioma growth over time. Here we document growth of a de novo intracranial capillary hemangioma, initially interpreted radiologically as a glioma. Methods: We report a case of a 64 year old male with history of HIV, recent Lyme disease and unconfirmed prior COVID-19 infection, who presented with exhaustion and confusion. Imaging demonstrated an intra-axial high T2/FLAIR signal lesion centred in the subcortical white matter of the posterior right temporal lobe. There was faint enhancement, and a few mildly prominent vessels were seen along its anterior aspect. Imaging 2 years prior had not shown the lesion. Stereotactic biopsy was nondiagnostic. Craniotomy and resection was carried out. Results: Pathological examination and immunohistochemistry returned the diagnosis of capillary hemangioma. We review how this case adds to proposed theories of de novo intracranial capillary hemangioma growth. Our patient’s co-morbidities support possible inflammation related triggers for symptomatic progression of these uncommon lesions. Conclusions: This unusual case documents the radiological appearance and progression of a de novo intracranial capillary hemangioma. It represents the first time such growth has been visualized in an adult male.

Background: Hydrocephalus is a common pediatric condition but many neurosurgeons cannot continue to care for patients into adulthood. Although gaps in care are thought to exist for youth transitioning to adult care, little is known about how patients/caregivers feel about the process. This study examined the perceptions of adolescents and young adults transitioning from pediatric to adult care at a single centre. Methods: We explored the perceptions of patients/caregivers with hydrocephalus about the transitioning process using semi-structured interviews and the qualitative research methodologies of grounded theory. 40 patient/caregivers (7 adolescents, 13 young adults, 20 parents) from BC Children’s Hospital and the Hydrocephalus Clinic at Vancouver General Hospital. Interviews were transcribed verbatim and coded, with common themes identified. Results: Four themes relating to transitioning from pediatric to adult care were identified: (1): Poor communiction; (2) Uncertainty relating to living life as an adult with hydrocephalus; (3) Anxiety and fear regarding navigating a new health care environment; (4) sadness in the loss of the relationship with the pediatric health care team. Conclusions: We identified a general dissatisfaction with the transitioning process for hydrocephalus. Common themes and concerns identified may form the basis of an improved transitioning model for youth with hydrocephalus as they become adults.

Background: Current literature provides little consensus on universal guidelines for first-line treatment of chronic subdural hematomas (cSDH). However, administration of local tissue plasminogen activator (tPA) may enhance the traditional method of twist drill drainage (TDD). The study aims to explore the efficacy of TDD with and without tPA, at achieving clinically relevant drainage (200mL) and reducing recurrence of cSDH. Methods: A retrospective review of patients (N=34) with cSDH is presented. Patients who received TDD with tPA (n=17) were identified and matched, based primarily on age and hematoma volume, to a control group (n=17), TDD without tPA. Variables of interest include initial hematoma volume, volume drained, length of stay, and recurrence rates. Descriptive analysis was run. Results: Average age for patients was 74.6 with 76% male. Mean drainage volumes for the tPA cohort was 381.6mL and TDD without tPA cohort was 151.3mL. The addition of tPA resulted in drainage volumes nearly double (1.9x) the clinically relevant amount and had low recurrence rates (12.5%). TDD without tPA failed to result in clinically relevant drainage and had a recurrence rate of 52.9%. Average length of stay differed by two days (9.71 tPA; 7.71 control). Conclusions: TDD with tPA was effective at treating cSDH in our population.

Background: Although 5% of cavernomas occur in the spine, intradural-extramedullary cavernomas are exceptionally rare. We present one such case of cavernoma associated exclusively with a nerve root, and review the literature for similar lesions. Methods: Case Report. A 45-year old male patient presented with a six-month history of numbness and paresthesia affecting his lower extremities bilaterally. MRI demonstrated a 16mm intradural-extramedullary lesion at T3-4, compressing the cord. The lesion was surgically removed en-bloc, requiring root sacrifice. The patient’s symptoms completely resolved post-operatively, and he remained asymptomatic at 3-month follow up. Results: Including the present case, 71 cases of intradural-extramedullary spinal cavernoma have been reported, including 50 with confirmed nerve root involvement. Patients most frequently presented between the ages of 40-59 (41%) with lesions at the lumbar level (54%). Confirmed subarachnoid hemorrhage was present in 14% at presentation, although 23% presented acutely. 49% presented with longstanding/progressive symptoms, and 11% with mixed acute-on-chronic presentation. 37% presented primarily with radiculopathy, 21% with myelopathy, and 11% with pain. Good postoperative recovery was documented in 80% of cases. Conclusions: Intradural-extramedullary spinal cavernomas may demonstrate a propensity for radiculopathy at presentation and exhibit substantial subarachnoid hemorrhage risk. Literature review supports the role of surgical resection.

Background: Extracranial traumatic vertebral artery injury (eTVAI) is common following non-penetrating head and neck trauma. Most cases are initially asymptomatic with an increased risk for stroke. Consensus is lacking regarding screening, treatment, and follow-up of asymptomatic patients with eTVAI. Our objective was to investigate national practice patterns reflecting these domains. Methods: An electronic survey was distributed via the Canadian Neurological Sciences Federation and Canadian Spine Society. Two case-based scenarios featured asymptomatic patients with eTVAI. Case 1: non-displaced cervical lateral mass fracture; angiography stratified by luminal diameter reduction. Case 2: complex C2 fracture; angiography featuring pseudoaneurysm dissection. Analysis: descriptive statistics. Results: Response Rate: 108 of 182 participants (59%), representing 20 academic institutions.

Case 1: 78% of respondents would screen using CTA (97%), immediately (88%). Most respondents (97%) would initiate treatment, using aspirin (89%) for 3-6 months (46%).

Case 2: 73% of respondents would screen using CTA (96%), immediately (88%). The majority of respondents (94%) would initiate treatment, using aspirin (50%) for 3-6 months (35%). Thirty-six percent of respondents would utilize endovascular therapy.

In both cases, the majority of respondents would follow-up clinically or radiographically every 1-3 months, respectively. Conclusions: This study highlights consensus in Canadian practice patterns for the workup and management of asymptomatic eTVAI.

Background: The qualitative Degenerative Spondylolisthesis Instability Classification (DSIC) system defines pre-operative instability associated with degenerative lumbar spondylolisthesis (DLS) and facilitates surgical technique selection. Objectives: (1) propose a quantitative DSIC system; (2) compare objective measures to surgeon impressions of DLS-related instability. Methods: We conducted a multi-center prospective study of 408 adult patients undergoing surgery for DLS. Variables included in the quantitative classification were assigned point-values based on evidence quality. Scores were converted to DSIC Types: 0-2 points (“Stable”; Type I), 3 points (“Potentially Unstable”; Type II), 4-5 points (“Unstable”; Type III). Surgeons documented impressions of instability using the qualitative DSIC system. Results: Five variables were included in the quantitative DSIC: presence of facet effusion, preservation of disc height (<6.5mm), translation (>4mm), kyphotic or neutral disc angle in flexion, and presence of low back pain (LBP) (>5/10 intensity). Surgeons categorized higher degrees of instability than the preliminary quantitative DSIC system, in 130 patients (42%) (P < 0.001). Compared to procedures suggested by the quantitative DSIC system, more extensive surgical procedures were performed in 150 patients (57%) (P < 0.001). Conclusions: A quantitative DSIC system allowed DLS-related stability to be scored and categorized. Patients potentially received more extensive surgery than warranted based on quantitative assessments of stability.

Background: A correlation between the nerve root sedimentation sign (SedSign) and neurogenic claudication has been demonstrated; though it did not account for leg-dominant pain. This study analyzed the utility of SedSign to diagnose leg-dominant pain using validated classification systems. Methods: We retrospectively reviewed prospective data from 367 patients with back or leg pain collected between January 1, 2012 to May 31, 2018. Baseline characteristics included SSPc (Saskatchewan Spine Pathway classification), Oswestry disability index (ODI), visual analogue pain scores (VAS), and EuroQol Group 5-Dimension Self-Report (EQ5D). Inter- and intra-rater reliability for SedSign was 73% and 91%. Results: SedSign was positive in 111 (30.2%) and negative in 256 (69.8%) patients. Univariate analysis showed a correlation between SedSign and age, male sex, ODI, EQ5D, cross-sectional area (CSA) of stenosis, antero-posterior diameter of stenosis, and leg-dominant pain; negative SedSign was correlated with back-dominant pain. Multivariate analysis revealed an association between SedSign and age, male sex, CSA stenosis, and ODI walking distance. The sensitivity, specificity, positive and negative predictive values of SedSign for leg-dominant pain were 33.5%, 83.2%, 77.0%, and 57.3%. Conclusions: SedSign has high specificity but low sensitivity for leg-dominant pain. Despite a similar correlation between SedSign and neurogenic claudication or sciatica, significance was lost on multivariate analysis.

Background: Spinal cord injuries invoke enormous life changes for the individual, with impacts not just on physical functioning, but social and psychological well-being. Individuals learn to deal with these changes, and handle these new stressors in different ways. Extant literature suggest the majority of people eventually attain a quality of life (QoL) simular to able-bodied individuals. We sought to validate these observations in a contemporary cohort and specifically explore how patients’ perceptions evolve over time. Methods: We conducted hour-long semi-structured interviews with 15 individuals living with cervical spinal cord injuries. Interviews took place over the telephone or virtually via MS Teams. Interview transcripts were then analyzed using an iterative coding process and thematic analysis (NVivo). Results: The over-arching journey that most participants described was a continuous evolution in QoL, as they learned to adapt and function with their injury. However, these trajectories were disparate and heavily reliant on personal supports and resources available, their psychosocial enviornment and inherent coping strategies. Conclusions: This study emphasizes the unique nature of each person’s journey, and not all people attain a satisfactory QoL. Our approach needs to be individualized, adjusting to specific circumstances, in order to provide more inclusive and supportive care.

Background: A subset of patients experience poor outcomes following anterior cervical discectomy and fusion (ACDF). Our study aimed to identify postoperative trajectories of disability, neck/arm pain and determine baseline measures that predict subgroup membership. Methods: Patients with cervical spondylotic radiculopathy undergoing ACDF are presented. Prognostic factors comprised demographic, health and surgery-related variables. Study outcomes were trajectories of neck disability index scores, numeric rating scales for neck/arm pain modeled with latent-class growth analysis. Associations were explored using robust Poisson models and reported with risk ratios and 95% confidence intervals. Results: Patients (N = 352; mean (SD) age = 50.9(9.5) years, 43.8% female) identified trajectories for disability (excellent=45.3%,fair=39.2%,poor=15.5%),arm pain (excellent=24.5%,good=52.0%,poor=23.5%),and neck pain (excellent=13.7%,good=63.1%,poor=23.2%). Greater physical and mental health-related quality of life were associated with a reduced risk of poor outcome(per SD,0.40[0.30,0.53]-0.80[0.65,0.99]), while higher risk for depression (per SD, 1.36[1.12,1.65]-2.26[1.84,2.78]), longer wait time(per 90 days, 1.31[1.05,1.63]-1.64[1.20,2.24]), and longer procedure time (per 30 min,1.07[1.03,1.10]-1.08[1.05,1.12]) were associated with an increased risk of poor outcome for all outcomes. Poor disability was increased with self-reported depression(3.03[1.76,5.21]), greater neck-to-arm pain ratio (2.63 [1.28 to 5.40]), ASA score > 2(2.26[1.33,3.83]), and preoperative opiates (2.05[1.18,3.56]), while preoperative physiotherapy (0.51[0.30, 0.88]), spinal injections (0.48[0.23 to 0.98]), and regular exercise (0.44 [0.24, 0.79]) decreased risk. Receiving compensation and smoking were associated with poor outcome for neck pain. Remaining candidate prognostic factors were not associated with clinical outcome. Conclusions: Perioperative factors were shown to decrease risk of poor outcomes for pain and disability two years following ACDF.

Background: Intracerebral hemorrhage (ICH) is caused by the rupture of a blood vessel, resulting in bleeding into the brain. This type of stroke accounts for 12-15% of all strokes and is the most fatal type of stroke (40% mortality rate). ICH stroke presents a greater burden to survivors as 90% of ICH survivors have some degree of disability. Because of the poor patient outcomes, there is a clear need for identifying new treatments as well as establishing the efficacy of existing treatments. Methods: Using previously described techniques we aim to establish a mouse model of ICH at the University of Saskatchewan. We observed them at a 1- 24-, 48- and 72hr mark post-stroke and scored for neurological deficits. Results: We currently have conducted 23 model trials. We have data on mice at 1-, 24, and 72 hr post-stroke. We have observed and begun to analyze a lesion area that can be seen in H&E stained sections, and further assessed with FTIR, and synchrotron modalities. Conclusions: We have analyzed several of the specimens with FTIR imaging and synchrotron analysis with the Canadian Light Source. We have preliminary results of the progression of metabolites in the hematoma and peri-hematoma zone of the ICH.