Recurrent lumbar disc herniation is a common disease process. It has been noted to occur in 5 to 15% of cases surgically treated for primary lumbar disc herniation. Outcomes in one series approached those after the initial operations, although this is not the case in the experience of most surgeons. The removal of recurrent lumbar disc herniations requires meticulous surgical technique. Great care is taken to identify the osseous margins of the previous surgical site. Identification and dissection of scar from the dura mater is greatly aided with the use of a microscope.

OBJECTIVE Excessive dissatisfaction and stress among physicians can precipitate burnout, which results in diminished productivity, quality of care, and patient satisfaction and treatment adherence. Given the multiplicity of its harms and detriments to workforce retention and in light of the growing physician shortage, burnout has garnered much attention in recent years. Using a national survey, the authors formally evaluated burnout among neurosurgery trainees. METHODS An 86-item questionnaire was disseminated to residents in the American Association of Neurological Surgeons database between June and November 2015. Questions evaluated personal and workplace stressors, mentorship, career satisfaction, and burnout. Burnout was assessed using the previously validated Maslach Burnout Inventory. Factors associated with burnout were determined using univariate and multivariate logistic regression. RESULTS The response rate with completed surveys was 21% (346/1643). The majority of residents were male (78%), 26-35 years old (92%), in a stable relationship (70%), and without children (73%). Respondents were equally distributed across all residency years. Eighty-one percent of residents were satisfied with their career choice, although 41% had at some point given serious thought to quitting. The overall burnout rate was 67%. In the multivariate analysis, notable factors associated with burnout included inadequate operating room exposure (OR 7.57, p = 0.011), hostile faculty (OR 4.07, p = 0.008), and social stressors outside of work (OR 4.52, p = 0.008). Meaningful mentorship was protective against burnout in the multivariate regression models (OR 0.338, p = 0.031). CONCLUSIONS Rates of burnout and career satisfaction are paradoxically high among neurosurgery trainees. While several factors were predictive of burnout, including inadequate operative exposure and social stressors, meaningful mentorship proved to be protective against burnout. The documented negative effects of burnout on patient care and health care economics necessitate further studies for potential solutions to curb its rise.

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Cerebrovascular research suffers from a lack of reliable methods with which to deliver exogenous substances effectively into the central nervous system (CNS) of small experimental animals. Here we describe a novel vessel microport surgical technique for a variety of cerebrovascular applications that is reproducible and well tolerated in mice. The procedure is based on the insertion of a vessel microport into the external carotid artery for substance delivery into the CNS via the internal carotid artery. The method results in selective substance delivery into the ipsilateral hemisphere. Other novel aspects of this surgical technique include the ability to perform multiple injections, study of conscious mice well removed from surgery, and lack of occlusion of the common or internal carotid artery that allows carotid flow to be maintained. The feasibility of this technique has been validated by infusion of HIV Tat protein to induce permeability of the blood-brain barrier and by implantation of tumor cells to establish a brain metastasis model. Thus, the described vessel microport technique can be employed in a variety of cerebrovascular research applications. KeywordsCNS drug delivery; vessel port; mouse carotid artery surgery; HIV Tat protein; brain metastasis Substance delivery into the brain has been the main obstacle in cerebrovascular research and clinical practice (Begley, 2004;Muller et al., 2006;Reddy et al., 2006;Witt and Davis, 2006;de Boer and Gaillard, 2007;Pardridge, 2007). Part of these difficulties is due to the existence of the blood-brain barrier (BBB), which is formed of cerebral microvascular endothelial cells with the support and regulatory role of the surrounding astrocytes, pericytes, and neurons (Abbott et al., 2006;Kim et al., 2006). Several strategies have been developed to facilitate substance delivery to targeted areas in the CNS (Bickel et al., 2001;Misra et al., 2003;de Boer and Gaillard, 2007;Kumar et al., 2007). For example, exogenous substances can be administered into the nasal or ophthalmic organs. The substance can then enter the CNS through the olfac-tory or ophthalmic nerves in an axoplasmic transport manner. However, a low applicable dosage and slowness in the delivery limit its application (Thorne et al., 1995;Vyas et al., 2005). Other forms of local administration are intra-sheath, intracerebral, or intraventricular injections or implants (Frisella et al.,2001;Wei et al., 2001;Wu et al., 2006;Pignataro et al., 2007 substance delivery into the surgically targeted structures, these approaches are traumatic to the CNS, and the administered volume is limited to small amounts. In addition, they are associated with a quick removal by the cerebrospinal fluid (CSF) and/or low penetration range to the brain parenchyma (Sugiyama et al., 1999;Pardridge, 2002).Because of the limitations of local substance delivery, a systemic delivery remains the most popular means of administration of exogenous substances into the brain. The most commonly used are the oral-intestine, pulmonary, ...

Only after an extensive workup, including 3 biopsies of the affected area was the diagnosis of Kümmell's disease considered and surgical treatment performed. CONCLUSION.: Delayed vertebral body collapse, i.e., Kümmell's disease, needs to be considered in any patient with recurrent or worsening spinal symptoms. Under-recognition of this condition leads to delayed diagnosis and treatment.

Recent attention has been given to gender differences in neurotrauma, and the anecdotal suggestion is that females have better outcomes than males, suggesting that circulating levels of estrogen (E(2)) may be neuroprotective. In order to address this issue, both young adult male and ovariectomized female rats were subjected to a T10 spinal cord injury (SCI), and E2 levels were maintained at chronic, constant circulating levels. Animals were clinically evaluated for locomotor changes using the Basso-Beattie-Bresnahan (BBB) scoring system. Morphologic differences were evaluated with unbiased stereology. Data analysis failed to reveal any significant benefit for the E2 therapy in either males or females. We did find a non-estrogen-dependent difference between male and female rats in length of injury, and percent of spared tissue, with female outcomes more favorable. These results suggest that E(2) does not provide a viable therapy following SCI.

Dubowitz syndrome is a disorder involving craniofacial abnormalities, growth retardation and mental retardation. Approximately 142 cases have been reported, with various associated other anomalies. These include cardiovascular, urogenital and endocrine abnormalities, as well as a predisposition to infections and hematological malignancies. Scoliosis has been described in association with this syndrome, as have isolated vertebral abnormalities. There has, however, been no description of craniocervical abnormalities. We describe three Dubowitz patients with significant craniocervical abnormalities.

Epidemiology and genetic studies indicate that patients with telomere length shorter than average are at higher risk of dying from heart disease or stroke. Telomeres are located at the ends of eukaryotic chromosomes which demonstrate progressive length reduction in most somatic cells during aging. The enzyme telomerase can compensate for telomere loss during cell replication. The present study is aimed to investigate the contribution of telomerase to stroke and the blood-brain barrier (BBB) dysfunction. Telomerase reverse transcriptase knock-out (TERT−/−) mice and littermate controls with normal TERT expression were subjected to a 24 h permanent middle cerebral artery occlusion (pMCAO). The stroke outcomes were assessed in terms of neurological scores and infarct volumes. In addition, we evaluated oxidative stress, permeability across the BBB, and the integrity of tight junctions in brain microvessels. Neurological testing revealed that TERT−/− mice showed enhanced deficits as compared to controls. These changes were associated with a greater infarct volume. The expression of tight junction protein ZO-1 decreased markedly in ischemic hemispheres of TERT−/− mice. The brain microvessels of TERT−/− mice also were more susceptible to oxidative stress, revealing higher superoxide and lower glutathione levels as compared to mice with normal TERT expression. Importantly, TERT deficiency potentiated the production of inflammatory mediators, such as TNF-alpha, IL-1beta and ICAM-1 in the ischemic hemispheres of mice with pMCAO. Our study suggests that TERT deficiency can predispose to the development of stroke in an experimental model of this disease.