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Operculoinsular cortectomy for refractory epilepsy is a relatively safe therapeutic option but temporary neurological deficits after surgery are frequent. A study of Bouthillier et al. highlighted the role of frontal/parietal opercula resections in postoperative complications. Corona radiata ischemic lesions are not clearly related to motor deficits. There were no obvious permanent neurological consequences of losing a part of an epileptic insula, including on the dominant side for language. A low complication rate can be achieved if the following conditions are met: 1) microsurgical technique is applied to spare cortical branches of the middle cerebral artery; 2) the resection of an opercula is done only if the opercula is part of the epileptic focus; and 3) the neurosurgeon involved has proper training and experience 1).
The goal of a study of Bouthillier et al. of the Sainte-Justine University Hospital Center, Montreal, Quebec, Canada, was to document seizure control outcome after operculoinsular cortectomy in a group of patients investigated and treated by an epilepsy team with 20 years of experience with this specific technique.
Clinical, imaging, surgical, and seizure control outcome data of all patients who underwent surgery for refractory epilepsy requiring an operculoinsular cortectomy were retrospectively reviewed. Tumors and progressive encephalitis cases were excluded. Descriptive and uni- and multivariate analyses were done to determine seizure control outcome and predictors.
Forty-three patients with 44 operculoinsular cortectomies were studied. Kaplan-Meier estimates of complete seizure freedom (first seizure recurrence excluding auras) for years 0.5, 1, 2, and 5 were 70.2%, 70.2%, 65.0%, and 65.0%, respectively. With patients with more than 1 year of follow-up, seizure control outcome Engel class I was achieved in 76.9% (mean follow-up duration 5.8 years; range 1.25-20 years). With multivariate analysis, unfavorable seizure outcome predictors were frontal lobe-like seizure semiology, shorter duration of epilepsy, and the use of intracranial electrodes for invasive monitoring. Suspected causes of recurrent seizures were sparing of the language cortex part of the focus, subtotal resection of cortical dysplasia/polymicrogyria, bilateral epilepsy, and residual epileptic cortex with normal preoperative MRI studies (insula, frontal lobe, posterior parieto-temporal, orbitofrontal).
The surgical treatment of operculoinsular refractory epilepsy is as effective as epilepsy surgery in other brain areas. These patients should be referred to centers with appropriate experience. A frontal lobe-like seizure semiology should command more sampling with invasive monitoring. Recordings with intracranial electrodes are not always required if the noninvasive investigation is conclusive. The complete resection of the epileptic zone is crucial to achieving good seizure control outcome 2).
In 2017 Bouthillier et al. published twenty-five patients underwent an epilepsy surgery requiring an operculoinsular cortectomy: mean age at surgery was 35 y (9-51), mean duration of epilepsy was 19 y (5-36), 14 were female, and mean duration of follow-up was 4.7 y (1-16). Magnetic resonance imaging of the operculoinsular area was normal or revealed questionable nonspecific findings in 72% of cases. Investigation with intracranial EEG electrodes was done in 17 patients. Surgery was performed on the dominant side for language in 7 patients. An opercular resection was performed in all but 2 patients who only had an insulectomy. Engel class I seizure control was achieved in 80% of patients. Postoperative neurological deficits (paresis, dysphasia, alteration of taste, smell, hearing, pain, and thermal perceptions) were frequent (75%) but always transient except for 1 patient with persistent mild alteration of thermal and pain perception. 3).
For students beginning their medical education, the neuroscience curriculum is frequently seen as the most difficult, and many express an aversion to the topic. A major reason for this aversion amongst learners is the perceived complexity of neuroanatomy 1).
Osler created the first residency program for specialty training of physicians, and he was the first to bring medical students out of the lecture hall for bedside clinical training. Historically, medical student education in neurological surgery has generally limited student involvement to assisting in research projects with minimal formal clinical exposure before starting sub-internships and application for the neurosurgery match. Consequently, students have generally had little opportunity to acquire exposure to clinical neurosurgery and attain minimal proficiency 2).
Lubelski et al. sought to identify successful practices that can be implemented to improve medical student recruitment to neurosurgery.
United States neurosurgery residency program directors were surveyed to determine the number of medical student rotators and medical students matching into a neurosurgery residency from their programs between 2010 and 2016. Program directors were asked about the ways their respective institutions integrated medical students into departmental clinical and research activities.
Complete responses were received from 30/110 institutions. Fifty-two percent of the institutions had neurosurgery didactic lectures for 1st- and 2nd-year medical students (MS1/2), and 87% had didactics for MS3/4. Seventy-seven percent of departments had a neurosurgery interest group, which was the most common method used to integrate medical students into the department. Other forms of outreach included formal mentorshipprograms (53%), lecture series (57%), and neurosurgery anatomy labs (40%). Seventy-three percent of programs provided research opportunities to medical students, and 57% indicated that the schools had a formal research requirement. On average, 3 medical students did a rotation in each neurosurgery department and 1 matched into neurosurgery each year. However, there was substantial variability among programs. Over the 2010-2016 period, the responding institutions matched as many as 4% of the graduating class into neurosurgery per year, whereas others matched 0%-1%. Departments that matched a greater (≥ 1% per year) number of medical students into neurosurgery were significantly more likely to have a neurosurgery interest group and formal research requirements. A greater percentage of high-matching programs had neurosurgery mentorship programs, lecture series, and cadaver training opportunities compared to the other institutions.
In recent decades, the number of applicants to neurosurgery has decreased. A major deterrent may be the delayed exposure of medical students to neurosurgery. Institutions with early preclinical exposure, active neurosurgery interest groups, research opportunities, and strong mentorship recruit and match more students into neurosurgery. Implementing such initiatives on a national level may increase the number of highly qualified medical students pursuing neurosurgery 3).
A medical student training camp was created to improve the preparation of medical students for the involvement in neurological surgery activities and sub-internships.
A 1-day course was held at Weill Cornell Medicine, which consisted of a series of morning lectures, an interactive resident lunch panel, and afternoon hands-on laboratory sessions. Students completed self-assessment questionnaires regarding their confidence in several areas of clinical neurosurgery before the start of the course and again at its end.
A significant increase in self-assessed confidence was observed in all skill areas surveyed. Overall, rising fourth year students who were starting sub-internships in the subsequent weeks reported a substantial increase in their preparedness for the elective rotations in neurosurgery.
The preparation of medical students for clinical neurosurgery can be improved. Single-day courses such as the described training camp are an effective method for improving knowledge and skill gaps in medical students entering neurosurgical careers. Initiatives should be developed, in addition to this annual program, to increase the clinical and research skills throughout medical student education 4).
Medical students in Canada must make career choices by their final year of medical school. Selection of students for a career in neurosurgery has traditionally been based on marks, reference letters and personal interviews. Studies have shown that marks alone are not accurate predictors of success in medical practice; personal skills and attributes which can best be assessed by reference letters and interviews may be more important. A study was an attempt to assess the importance of, and ability to teach, personal skills and attitudes necessary for successful completion of a neurosurgical training program.
A questionnaire was sent to 185 active members of the Canadian Neurosurgical Society, asking them to give a numerical rating of the importance of 22 personal skills and attributes, and their ability to teach those skills and attributes. They were asked to list any additional skills or attributes considered important, and rate their ability to teach them.
Sixty-six (36%) questionnaires were returned. Honesty, motivation, willingness to learn, ability to problem solve, and ability to handle stress were the five most important characteristics identified. Neurosurgeons thought they could teach problem solving, willingness to consult informed sources, critical thinking, manual dexterity, and communication skills, but honesty, motivation, willingness to learn and ability to handle stress were difficult or impossible to teach.
Honesty, motivation, willingness to learn, problem solving and Stress management are important for success in a neurosurgical career. This information should be transmitted to medical students at “Career Day” venues. Structuring letters of reference and interviews to assess personal skills and attributes will be important, as those that can’t be taught should be present before the start of training 5).