Neurosurgical faculty and resident perspectives on collective bargaining efforts by resident physicians in the United States

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In a survey study Agarwal et al. from the UPMC, Pittsburgh (Agarwal et al.); U Michigan, Ann Arbor (Zaki et al.) published in the *Journal of Neurosurgery* to evaluate neurosurgical faculty and trainee opinions on resident physician unionization via a 17‑question national survey. Survey sent to 551 faculty (chairs, PDs, SNS members) and 1,728 trainees (residents/fellows). Response rate was 17.8% (182 faculty, 223 trainees). Categorical responses analyzed with chi-square; significance at p < 0.05.

* Key Findings:

  • Faculty: 70% opposed unions; 54% felt unions negatively affect patient care; 80% feared strikes; 85% believed current channels were sufficient.
  • Trainees: Only 16% opposed unions; 9% thought unions impact patient care negatively; 27% feared strikes; 47% believed existing channels adequate (all p < 0.001).
  • Among those at programs with existing unions, 34.2% of faculty and 12.1% of trainees reported negative consequences—most commonly inability to enact discipline‑specific departmental changes.
  • Conversely, 84.8% of unionized residents cited benefits: enhanced pay, duty hours protection, parental leave, parking, and educational allowances

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Critical Analysis

* Strengths:

  • National reach and representation of both faculty and trainees.
  • Direct comparison reveals stark divergence in perspectives.
  • Mix of quantitative and qualitative feedback on union effects.

* Limitations:

  • Modest response rate (17.8%) poses risk of non-response and selection biases.

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Chiari: From the Foramen Magnum to the Psychiatrist’s Couch

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The history of Chiari malformation type I could have quietly remained in the corner of neurosurgical anomalies with clear surgical indications: typical occipital headache, syringomyelia, obstructive hydrocephalus, brainstem or spinal cord compression. But no. We had to ruin it. What was once a structural diagnosis with sound criteria has now become an emotional wildcard, a totemic diagnosis, a kind of “everything goes through here” in the form of herniated cerebellar tonsils.

And then someone said: “What if Chiari also explains anxiety?”

And the worst part isn’t that someone said it. The worst part is that someone else listened… and ordered an MRI. And someone else went ahead and operated.

Editorial with a scalpel (an intellectual one)

Thankfully, Annie I. Drapeau and Anthony M. Kaufmann from Manitoba decided to write this editorial in the Journal of Neurosurgery (February 2025). Because things were getting out of hand. Their text is not just a warning; it’s an elegant slap in the face of white-coated surgical delusion. With calm, method, and references, the authors remind us of the basics: that performing posterior fossa decompression (PFD) for cognitive dysfunction without clear compressive signs is, at best, wishful thinking—and at worst, a Freudian regression with a Stryker saw.

They rightly highlight the confusion in studies lacking control groups, psychiatric baseline profiles, or medication adjustments. Improvement after surgery? It might be because they stopped topiramate. Or because someone said “everything will be fine.” Or maybe just because the neck pain is gone. But jumping from that to saying we’ve “freed trapped thoughts” is a leap that no extended foramen magnum opening can cover.

Cerebellum mania and its excesses

Of course, it doesn’t help that we’ve fallen in love with the cerebellum. Today everything is cerebellum. If the patient stumbles: ataxia. If they forget: dysmetria of thought. If they cry for no reason: cerebellar affective syndrome. If they yawn during ward rounds: expanding pontocerebellar syndrome. We’ve become such fans of the “cerebellar cognitive affective syndrome” that we’re just a couple of papers away from proposing transcranial cerebellar stimulation for procrastination and digital hypochondria.

But be careful: just because the cerebellum connects with the frontal cortex doesn’t mean it explains why your brother-in-law votes for Vox or why you feel sad some days. Attributing existential anxiety, executive dysfunction, or loss of libido to Chiari isn’t precision medicine—it’s neuropsychoanalysis in surgical scrubs.

And tomorrow?

If today we’re decompressing a Chiari for thought disorders, what’s next? Occipitocervical fusion for personality dissociation? Kyphoplasties for insecure attachment? Cosmetic cranioplasty for pathological narcissism? Spinal cord stimulators for existential emptiness?

The slippery slope is now more epistemological than clinical. We’ve moved from evidence-based neurosurgery to occurrence-based neurosurgery.

Final diagnosis: compensated surgical delusion

The editorial by Drapeau and Kaufmann deserves applause, broadcast on OR monitors, and honestly, embroidered on residents’ scrub caps. Because not everything seen on an MRI should be operated on—nor everything thought about thought.

Thought cannot be decompressed. Affectivity cannot be drained. And the posterior fossa is not a selective serotonin reuptake inhibitor.

References:

  1. Drapeau AI, Kaufmann AM. Editorial. Considering Chiari malformation type I decompression for disorders of thought. J Neurosurg. 2025 Feb 21;143(1):1-3. doi: 10.3171/2024.10.JNS242051. PMID: 39983123.

  2. Henry LC, McDowell MM, Stephenson TL, et al. Predecompression and postdecompression cognitive and affective changes in Chiari malformation type I. J Neurosurg. 2025 Feb 21;143(1):4-12. doi: 10.3171/2024.8.JNS241363. PMID: 39983117.

Anthropometrics, cancer risks, and survival outcomes in adult patients with glioma – a systematic review and meta‑analysis

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In a systematic review and meta‑analysis Ahn et al. from St. Mary’s Hospital, Seoul; The Catholic University of Korea, Seoul published in Acta Neurochirurgica to evaluate associations between height, body mass index (BMI), and both the risk and prognosis of glioma andglioblastoma through aggregated epidemiological data Taller stature increases risk of glioma/glioblastoma (HR per +10 cm ~1.19–1.25). Higher BMI modestly elevates incidence risk (RR ~1.08; HR per +5 kg/m² ~1.01–1.02) and correlates with improved survival in glioblastoma (HR ~0.75).

Critical Review

* Study design & scope:

  1. Solid use of PRISMA flow, Newcastle–Ottawa scoring. 23 studies from large databases until Jan 31, 2024.
  1. Random‑effects model appropriate given heterogeneity.

* Strengths:

  1. Broad dataset; consistency in directionality of height risk.
  1. Quantitative measures (HR/RR) allow clinical interpretation.

* Weaknesses:

  1. Residual confounding: socioeconomic status, comorbidities, treatment variations not fully accounted.

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Novel planning pipeline utilizing the Surgical Theater system for pediatric epilepsy surgery

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In a retrospective institutional experience with illustrative cases Shields LB et al. from the Norton Neuroscience Institute, Louisville published in Epilepsia Open to evaluate the role of the Surgical Theater (ST) 3D visualization system in enhancing presurgical planning for pediatric epilepsy surgery. The ST system enabled integration of multimodal imaging into immersive 3D models, improving collaborative surgical planning, enhancing intraoperative navigation, and allowing VR-based procedural rehearsal. It demonstrated utility across 85 cases and is posited as a promising adjunct for pediatric epilepsy surgical workflows 1)

Critical Review

This is a descriptive, non-comparative experience report centered on implementing the Surgical Theater (ST) system in a pediatric epilepsy context. While the authors present a visually compelling and potentially transformative workflow for presurgical planning, the study is methodologically weak—it lacks controls, quantifiable outcomes, or statistical rigor. The “results” are largely anecdotal, with 4 case examples insufficiently discussed in terms of surgical impact or clinical outcomes.

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AO Spine Knowledge Forum Deformity. Alignment Goals in Adult Spinal Deformity Surgery

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In a narrative review Pizones et al. from La Paz Univ. Hosp, Madrid; additional centers in San Antonio, San Diego, Toronto, Barcelona, Charlottesville, New York published in the Global Spine Journal to critically examine evolving strategies in sagittal alignment targets for adult spinal deformity surgery, shifting focus from generic HRQoL goals to preventing mechanical complications Traditional alignment metrics (PI‑LL, SVA, TK) are limited for personalized planning; compensatory strategies (pelvic retroversion, knee flexion) are essential; individualized, structure-shape–based alignment (e.g., GAP, Roussouly, T4‑L1‑Hip‑Axis) reduces mechanical failure risk, though reoperation rates remain high 1).

Critical Review

The narrative review offers a comprehensive appraisal of alignment paradigms, yet:

* Strengths: Integrates key classification systems; emphasizes pelvic and lower-extremity compensation; aligns recent evidence on shape-based vs. quality-of-life–based targets; timely discussion given recent advances (e.g., T4‑L1‑Hip‑Axis)

* Weaknesses: Lacks systematic methodology or quantitative synthesis; conclusions primarily descriptive; limited critical appraisal of conflicting literature; evidence grade unclear

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All‑pedicle screw posterior spinal fusion after magnetically controlled growing rods in walking early‑onset scoliosis patients: radiographic and surgical outcomes

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In a retrospective cohort study De Salvatore et al. from the Bambino Gesù Children’s Hospital, Rome; Università Campus Bio‑Medico di Roma, Rome published in the *Spine Deformity Journal* to assess radiographic correction and complications after final posterior spinal fusion in Early-Onset Scoliosis (EOS) patients initially treated with magnetically controlled growing rods (MCGR). Definitive fusion yields significant improvements in coronal curve (mean reduction from 45.5° to 33.5°) and thoracic kyphosis (from 19.8° to 13.5°), sustained at ≥2‑year follow‑up. Major complication rate was low (18.5%, one major) 1).

Critical review

– Strengths:

  1. Focus on a clinically relevant patient group (walking EOS post-MCGR).
  2. Objective measurement of both coronal and sagittal parameters with adequate follow-up.

– Limitations:

  1. Small sample (n=27) limits statistical power and heterogeneity evaluation.

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Cerebral Chromoblastomycosis: A Unique Presentation of Dematiaceous Fungal Infection in an Immunocompromised Patient

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In a case report – culture/histopathology confirmed. Norton Stephen et al. from AIIMS Madurai (Madurai), JIPMER Puducherry (Puducherry), Neurosurgery JIPMER Puducherry. published in Annals of Indian Academy of Neurology. to report an unusual intracranial dematiaceous fungal infection (“cerebral chromoblastomycosis”) in an immunocompromised host. Demonstrates that dematiaceous fungi can invade the CNS in immunosuppressed patients, presenting as brain abscesses; underscoring need for high suspicion, tissue diagnosis, and tailored antifungal therapy 1).

Critical Review

1. Novelty & Rigor:

  1. Rare case: cerebral infection by pigmented dematiaceous fungus is exceedingly uncommon. Prior reports mostly in immunocompetent individuals
  2. Methodology strong: pathology plus culture confirmation; however, imaging, antifungal regimen, and clinical course not detailed in provided abstract.

2. Limitations:

  1. Lack of comprehensive clinical data: dose/duration of therapy, immune status specifics (CD4, neutrophils), imaging, follow-up.

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Interstitial Thermal Therapy in Mesial Temporal Lobe Epilepsy

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In a prospective multicenter registry (LAANTERN), observational cohort Landazuri et al. from the University of Kansas Medical Center, Kansas City; Washington University, St. Louis; Duke University, Durham; University of Louisville, Nashville; Norton Health Care, Louisville; UT Southwestern, Dallas; Mount Sinai, New York; Yale, New Haven; University of Pittsburgh; UC San Diego; UAMS, Little Rock; Northwestern, Chicago; United Children’s St. Paul; Geisinger, Danville; AdventHealth, Orlando. published in JAMA Neurology to evaluate seizure outcomes, procedural safety, and QoL following laser interstitial thermal therapy in drug‑resistant mesial temporal lobe epilepsy. Over 50% of patients achieved Engel I or ILAE 1/2 seizure freedom at 2 years with mild, transient adverse events and QOL improvement in this large real‑world cohort

Critical Review

  • Strengths:
    • Largest prospective, multicenter US LITT registry for MTLE with 145 participants and extended 2‑year follow‑up
    • Rigorous real‑world data from 15 level IV epilepsy centers, with both adult and pediatric patients
    • Comprehensive data on procedural metrics (e.g., ablation volume, operating time, LOS) and seizure/QoL outcomes
  • Limitations:
    • No surgical comparator arm (e.g., open anterior temporal lobectomy), limiting comparative effectiveness assessment
    • Potential selection bias: centers specialized in LITT pathways and inclusion criteria requiring ≥6 months follow‑up
    • Heterogeneous etiology (MTS vs MRI‑negative) may mask subpopulation differences; no predictors of outcome identified
    • Median follow‑up limited to 2 years; long‑term seizure freedom and delayed complications remain unclear

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Total corpus callosotomy for an adult patient with progressive myoclonic epilepsy associated with dentatorubral-pallidoluysian atrophy: illustrative case

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In a single-patient illustrative case, Mine et al., from Kyushu University, Fukuoka, Japan, published in the Journal of Neurosurgery Case Lessons, report the first adult case of Dentatorubral-pallidoluysian atrophy (DRPLA)-associated progressive myoclonic epilepsy (PME) treated with a total corpus callosotomy (CC) for refractory seizures.

→ Outcome: Total CC led to a marked reduction in seizure frequency. Tonic seizures and FBTCSs with desaturation resolved by 1 year, with notable improvement in quality of life (QOL).

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🔎 Critical Appraisal

  • 🟢 Strengths
    • Novelty: First reported adult DRPLA-PME corpus callosotomy.
    • Clearly disabling epilepsy: Myoclonus, tonic seizures, desaturation.
    • Clear outcome: Sustained seizure reduction at 1-year.
  • 🟡 Limitations
    • Single case → low external validity.
    • No comparator: No data vs. anterior CC or other therapies.
    • Cognitive effects unquantified.
    • DRPLA is a diffuse neurodegenerative disease; CC does not target focus directly.

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Glioma promotes macrophage immunosuppressive phenotype through ANXA1 in a methionine metabolism-dependent manner

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In a Translational research with bulk RNA sequencing analysis, scRNA-seq, and in vitro validation Hong Hu *et al.* from the Harbin Medical University published in the Journal: Discover Oncology to elucidate how methionine metabolism contributes to the immunosuppressive tumor microenvironment in gliomas, with a focus on macrophage polarization mediated by ANXA1. Elevated methionine metabolism in glioma cells correlates with higher WHO tumor grade and an immunosuppressive microenvironment. High methionine metabolic activity fosters M2 macrophage polarization via ANXA1, which is downregulated upon methionine deprivation 1).

Critical Review

This study leverages multi-omics datasets, particularly MMA-scoring and scRNA-seq, to draw a novel link between methionine metabolism and the immune suppressive phenotype in gliomas, focusing on macrophage polarization. The authors make a credible case for metabolic reprogramming as a driver of glioma malignancy. However, there are caveats:

– Strengths: The integration of bulk and single-cell RNA-seq enhances resolution, and the use of in vitro validation lends support to mechanistic claims. The correlation between MMA-scores and glioma grade is statistically compelling.

– Limitations: Despite the innovative premise, the study relies heavily on correlative data. Functional validation, particularly in vivo or using clinical samples, is lacking. The assertion that ANXA1-mediated macrophage polarization is solely Met-dependent needs further biochemical interrogation. Furthermore, patient sample heterogeneity and potential confounders are not adequately addressed.

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