Background: Current lumbar intervertebral disc prostheses provide suboptimal symptom relief with little natural load-cushioning. PVA-C is a promising biocompatible material, however previous studies from our lab show that it does not have adequate elastic modulus to mimic the annulus fibrosus. Here we present a prototype of an artificial lumbar intervertebral disc. Methods: The tensile properties of pure (5-35% PVA-C) and particle-reinforced (15% PVA-C with 5% of either Sephadex or hydroxyapatite) composite PVA-C formulations were evaluated. Simple tension and tensile stress relaxation tests were performed. Woven Teflon mesh was embedded in PVA-C and tested under compression. Endplate pull-out tests were performed. Results: Tensile testing showed that all PVA-C formulations behaved linearly for physiologic levels of strain (<20%). Tensile elastic modulus is an order of magnitude lower than the annulus fibrosus. Teflon has similar elastic modulus as collagen and compression of the hybrid Teflon-PVA-C construct revealed good biomechanical mimicry with elastic modulus of 20-25MPa at 20% deformation, similar to human data. Bonding between PVA-C and porous titanium endplate is excellent. Conclusions: A fiber-reinforced PVA-C impregnated composite adequately mimics the annulus fibrosus. Our prototype of a tissue mimicking artificial intervertebral disc utilizes a woven Teflon fiber with 20% PVA-C (+Hydroxyapatite) annulus and 5% pure PVA-C nucleus bonded to porous titanium foam endplates.

Background: Pelvic peripheral nerve sheath tumors (PNST), which includes neurofibroma, schwannoma, and MPNST, are rare tumors located in the retroperitoneum. Methods: The case records of a prospectively maintained database at Sunnybrook Health Sciences Center (SHSC) were reviewed to identify patients with pelvic PNST, managed between 2006 - 2016. Medical records were retrospectively reviewed for patient demographics, presentation, tumor location, symptoms, imaging characteristics, management, and outcome. The surgical technical caveats were described. An English language literature review was performed to describe previously published experiences. Results: The series consisted of 7 patients, ranging from 22 - 74 years of age at presentation. These lesions tend to be large at the time of diagnosis, and presenting symptoms include abdominal, flank, or back pain, as well as leg edema or hydronephrosis from local compression. Most patients in this cohort were managed surgically with midline abdominal transperitoneal exposures. Lastly, 5 tumors were benign schwannomas managed with gross total resection or debulking, while 2 patients had MPNSTs managed with biopsy followed by adjuvant chemoradiation therapy. Conclusions: In this case series, we describe the characteristics, evaluation, and management of 7 patients with pelvic PNST at a major healthcare institution in Toronto, Canada, highlighting the technical aspects of managing this rare and challenging entity.

Background: Neurosurgery was first practiced in Victoria, BC in the 1950’s. It has grown from 1 neurosurgeon to 6 neurosurgeons today. Methods: Research into the beginning of Neurosurgery in Victoria demonstrates that it started with one surgeon and has grown significantly over the past 60 plus years. Results: Although Neurosugery started in Victoria with humble beginnings it has now developed into a sophisticated unit with 6 neurosurgeons with various subspeciality interests including complex and minimally invasive spine, cerebrovascular and neuro-oncology. Conclusions: The Neurosurgery division in Victoria has grown over the years from a single surgeon to 6 surgeons practicing a wide scope of neurosurgical procedures.

Background: Previously-identified deficiencies in stroke training for emergency and internal medicine trainees led us to develop a competency-based curriculum for a stroke rotation, based upon entrusbable professional activities (EPAs). EPAs are observable and measurable activities that are routine care within a given medical specialty. Methods: We surveyed stroke- and non-stroke neurologists using a modified Delphi process with two iterations. The survey sought input on the number and nature of EPAs considered most important and achievable during a one month stroke rotation. Results: Surveyed neurologists considered 5-10 EPAs as adequate and reasonable to achieve during a one month elective. A list of the most essential EPAs was obtained and will be used as the basis of a curriculum for rotating residents in Internal and Emergency medicine at the Island Medical Program in Victoria, BC. Conclusions: Our work highlights an approach to meeting an identified gap in resident training in an important area of neurology (stroke). A competency based approach to medical education, focusing on EPAs, offers an innovative way of approaching resident education that seeks to ensure residents develop skills that experts in the field have identified as most essential for the work at hand (in this case, the proper management of stroke patients).

Background: Needs assessment is a cornerstone of designing programs for continuing professional development (CPD). However, typical needs assessment surveys often yield non-specific information insufficient to guide professional development programming decisions. Methods: A survey was distributed to Neurologists practicing in city of Calgary. A stimulated-recall method was used to generate specific case-oriented clinical questions and 5-point Likert scales were used to rate specific topics across the CanMEDS competency framework and CPD preferences. Results: A total of 48 surveys were distributed, with a response rate of 62.5%. Most respondents were subspecialists in Neurology (87%) in practice for less than 15 years (71%). Most used local neuroscience (97%) rounds as source for CPD. Respondents reported a need to address specific questions relating to the following topics: Acute stroke (54%), non-acute stroke (45%) and epilepsy (50%). For example, physicians identified that they wanted to learn more about when to reinitiate anticoagulation following ischemic stroke, or which choice of anti-epileptic for various seizure presentations. Specific medical content was rated highly disproportionately to other physician competencies such as communication or management skills. Conclusions: Our survey elicited detailed learning gaps from academic neurologists and identified a disconnect in interest in topics related to medical content compared to other important physician competencies.

Background: Surgical simulation training offers trainees the opportunity to practice surgical skills before entering the operating room. The objectives of this study were to determine the effect of simulation for learning instruments for burr hole surgery and whether this learning is translated to real instrument recognition with retention. Methods: Randomized trials of PGY1 neurosurgery residents and perioperative nurses were conducted, using PeriopSim™ for instrument recognition, as well as real instruments. Group A performed simulation tasks using PeriopSim™ prior to identifying real instruments, whereas Group B identified real instruments prior to performing simulation tasks. Nurses’ recall was assessed at seven days. Results: Sixteen residents and 100 nurses were recruited. All participants showed significant overall improvement in their scores for simulated tasks. Group A demonstrated enhanced accuracy and speed of identifying real instruments compared with Group B (p<0.001). Furthermore, knowledge recall testing at one week demonstrated retained learning, shown by 97% accuracy in instrument identification. Conclusions: Our results demonstrate that recognition of surgical instruments improves with repeated use of the PeriopSim™ platform. Instrument knowledge acquired through simulation training results in improved identification and retained recognition of real instruments.

Background: Web 2.0 technologies (e.g. blogs, social networks, and wikis) are increasingly being utilized by medical schools and postgraduate training programs as tools for information dissemination. These technologies offer the unique opportunity to track metrics of user engagement and interaction. Here, we employ Web 2.0 technologies to assess academic behaviors among neurosurgery residents. Methods: We performed a retrospective review of all educational lectures, part of the core Neurosurgery Residency curriculum at the University of Toronto, posted on our teaching blog (www.TheBrainSchool.net) from Sept 2013 - Nov 2016. We looked for associations with lecturer’s academic position, timing of examinations, and lecture/subspecialty topic. Results: The overall number of clicks on 123 lectures was 1079. Most of these clicks were occurring during the in-training exam month (43%). Click numbers were significantly higher on lectures presented by faculty (mean 18.6, SD ± 4.1) compared to residents-delivered lectures (mean 8.4, SD ± 2.1) (P= 0.031). Functional neurosurgery lectures were the most downloaded (47%), followed by pediatric neurosurgery (22%). Conclusions: The current study demonstrates the value of Web 2.0 analytic tools in examining residents study behavior. Residents tend to ‘cram’ downloading lectures in the same month of training exams and display a preference for faculty-delivered lectures.

Background: Residency training programs aspire to develop residents’ research skills, but engaging trainees in research often proves challenging. Addressing this requires a better understanding of factors influencing residents’ engagement in scholarship. We sought to identify such factors through an interview-based study that explored residents’ interest and involvement in research during training. Methods: We conducted 15 semi-structured interviews with neurology (n=8) and neurosurgery (n=7) residents at our institution based on an interview guide developed through a literature review and pilot interviews (n=3). Using template analysis, we examined transcripts to identify facilitators and barriers to resident research. Results: Motivation, mentorship, and resource availability were noted to significantly impact resident research. Trainees indicated motivation is influenced by personal desire to develop research skills, interest in available projects, and pressure to engage in scholarship from peers, mentors, and future employers. While strong mentorship and departmental resources for data collection and analysis facilitate resident research, funding and time constraints are barriers to success. Conclusions: We have identified multiple factors influencing residents’ engagement in research, which may be targeted by program directors to optimize the post-graduate training environment for resident scholarship. In the next phase of our project, we will corroborate and expand on these findings through a national survey of residents across all specialties.

Background: Communicating with senior neurosurgical colleagues during residency necessitates a reliable and versatile smartphone. Smartphones and their apps are commonplace. They enhance communication with colleagues, provide the ability to access patient information and results, and allow access to medical reference applications. Patient data safety and compliance with the Personal Health Information Protection Act (PHIPA, 2004) in Canada remain a public concern that can significantly impact the way in which mobile smartphones are utilized by resident physicians Methods: Through the Canadian Neurosurgery Research Collaborative (CNRC), an online survey characterizing smartphone ownership and utilization of apps among Canadian neurosurgery residents and fellows was completed in April 2016. Results: Our study had a 47% response rate (80 surveys completed out of 171 eligible residents and fellows). Smartphone ownership was almost universal with a high rate of app utilization for learning and facilitating the care of patients. Utilization of smartphones to communicate and transfer urgent imaging with senior colleagues was common. Conclusions: Smartphone and app utilization is an essential part of neurosurgery resident workflow. In this study we characterize the smartphone and app usage within a specialized cohort of residents and suggest potential solutions to facilitate greater PHIPA adherence

Background: Despite being mandatory for accreditation by the RCPSC and ACGME, little is known about how ethics education is undertaken during neurosurgery training. This study assessed the current state of ethics education in North American neurosurgery training programs. Methods: A web-based survey was developed based on ethics competencies outlined by the RCPSC and the ACGME and emailed to North American neurosurgery residency program directors(PD’s). Responses were analyzed using descriptive statistics. Results: 47/119 (40%) PD’s completed the survey. Most(74%) spent <10 hours/year on ethics education. Informal discussion(86%), case presentations(67%) and lectures(55%) were common teaching methods. Most(85%) felt real-life experience was the best teaching method. Neurosurgical faculty(86% of programs), medical faculty(48%) and ethicists(26%) provided ethics teaching. Time constraints(42%) and lack of expert faculty(24%) were common barriers. Important topics were end of life care(95%), conflicts of interest(81%), informed consent(81%), futility(66%) and research ethics(66%). Most(78%) felt ethics education should be mandatory and that trainees were prepared to deal with ethically challenging situations(95%). Conclusions: This study provides a snapshot of ethics education in neurosurgery training. Time constraints and a lack of expert faculty were seen as barriers to ethics education. Most program directors felt residents were well prepared to deal with ethical issues. Identified ethical topics of importance should be incorporated into training curricula.

Background: No standardized method of resident operative-case logging exists. Our study sought to develop a standardized form used by residents to log operative-cases. Methods: Members of the Canadian Neurosurgery Research Collaborative (CNRC), a national resident-led research organization have created a standardized document based on the current Royal College objectives for operative procedures (section 5). Modifications to structure and content will be guided via consensus from Canadian neurosurgery program-directors. Results: Program directors in each CNRC collaborative institution will be asked to modify the standardized form. The CNRC currently involves thirteen of the fourteen Canadian neurosurgery residency programs. Additional consensus, if necessary, can be reached at the Royal College meeting for program directors of neurosurgery March 20th 2017. Conclusions: A standardized operative-case log represents the first step in a prospective study towards compiling operative volume of all Canadian neurosurgical residents over one academic year. Such data will be essential to guide informed decisions with regard to Royal College requirements as Canadian neurosurgical programs transition to a competency based framework.

Background: Palliative care is a cornerstone of the management of progressive neurological illness, but there lacks a standardized evidence-based curriculum to teach the unique aspects of neurology-based palliative care to current learners. Methods: A needs assessment involving focus groups with patients, physicians, interdisciplinary members, and trainees was conducted to identify gaps in the current curriculum. The Kolb Learning Style Inventory identified learning strategies among neurology residents. A Palliative Medicine Comfort and Confidence Survey and knowledge pre-test was distributed to determine current learner needs. The curriculum was delivered during academic time, and feedback was obtained for further content revision. Results: Qualitative analysis was used to develop the curriculum with the key principles of symptom management, end-of life communication, psychosocial components of care, and community coordination. Learning styles varied, but preference for active experimentation and concrete experience was noted. Learners identified as comfortable with withdrawal of medical interventions, but requiring support on home palliative care referral, and management of terminal delirium and dyspnea. Further teaching was requested for end of life ethics and communication skills. Conclusions: By integrating current best evidence-based practice in palliative neurology with learner feedback, this project aims to create a comprehensive palliative care curriculum for neurology learners.