British Journal of Neurosurgery

ISSN: 0268-8697 (Print) 1360-046X (Online) Journal homepage: https://www.tandfonline.com/loi/ibjn20

Effect of an additional neurosurgical resident on

procedure length, operating room time, estimated
blood loss, and post-operative length-of-stay

Anthony V. Nguyen, William S. Coggins, Rishabh R. Jain, Daniel W. Branch,

Randall Z. Allison, Ken Maynard & Rishi R. Lall

To cite this article: Anthony V. Nguyen, William S. Coggins, Rishabh R. Jain, Daniel W. Branch,
Randall Z. Allison, Ken Maynard & Rishi R. Lall (2019): Effect of an additional neurosurgical
resident on procedure length, operating room time, estimated blood loss, and post-operative length-
of-stay, British Journal of Neurosurgery, DOI: 10.1080/02688697.2019.1642446

To link to this article: https://doi.org/10.1080/02688697.2019.1642446

Published online: 22 Jul 2019.

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BRITISH JOURNAL OF NEUROSURGERY
https://doi.org/10.1080/02688697.2019.1642446

ORIGINAL ARTICLE

Effect of an additional neurosurgical resident on procedure length, operating

room time, estimated blood loss, and post-operative length-of-stay
Anthony V. Nguyena , William S. Cogginsa, Rishabh R. Jaina, Daniel W. Branchb, Randall Z. Allisonb, Ken
Maynardb and Rishi R. Lallb
a
School of Medicine, The University of Texas Medical Branch, Galveston, TX, USA; bDivision of Neurosurgery, The University of Texas Medical
Branch, Galveston, TX, USA

ABSTRACT ARTICLE HISTORY

Introduction: Neurosurgical residency training is costly, with expenses largely borne by the academic Received 15 February 2019
institutions that train residents. One expense is increased operative duration, which leads to poorer Revised 10 April 2019
patient outcomes. Although other studies have assessed the effect of one resident assisting, none have Accepted 8 July 2019
investigated two residents; thus, we sought to investigate if two residents versus one scrubbed-in
KEYWORDS
impacted operative time, estimated blood loss (EBL), and length-of-stay (LOS). Neurosurgery; neurosurgical
Methods: In this retrospective review of patients who underwent a neurosurgical procedure involving training; operating times;
one or two residents between January 2013 and April 2016, we performed multivariable linear regression operative experience;
to determine if there was an association between resident participation and case length, operating room outcome; reforms
time, EBL, and LOS. We also included patient demographics, attending surgeon, day of the week, start to training
time, pre-operative LOS, procedure performed, and other variables in our model. Only procedures per-
formed at least 40 times during the study period were analyzed.
Results: Of 860 procedures that met study criteria, 492 operations were one of six procedures performed
at least 40 times, which were anterior cervical discectomy and fusion, cerebrospinal fluid (CSF) shunt inser-
tion, CSF shunt revision, lumbar laminectomy, intracranial hematoma evacuation, and non-skull base,
supratentorial parenchymal brain tumor resection. An additional resident was associated with a 35.1-min
decrease (p ¼ .01) in operative duration for lumbar laminectomies. However, for intracranial hematoma
evacuations, an extra resident was associated with a 24.1 min increase (p ¼ .03) in procedural length.
There were no significant differences observed in the other four surgeries.
Conclusion: An additional resident may lengthen duration of intracranial hematoma evacuations.
However, two residents scrubbed-in were associated with decreased lumbar laminectomy duration.
Overall, an extra resident does not increase procedural duration, total operating room utilization, EBL, or
post-operative LOS. Allowing two residents to scrub in may be a safe and cost-effective method of edu-
cating neurosurgical residents.

Introduction in greater cost for the patient and institution.13,14 In contrast,

Neurological surgery residency training is expensive; a seven-year
neurosurgery residency was estimated by United States profes-
sional societies to cost 1.2 million dollars in 2012, with most of
the cost being covered by academic medical centers themselves.1
A portion of these expenditures stem from resident participation
in operative cases.
In one previous study, adult neurosurgical cases involving res-
idents took 34 min longer than matched, attending-only cases.2
While the association between resident involvement and patient
morbidity and mortality is currently an area of debate due to
possible confounders, there is much existing literature that
describes increased complications with longer procedures, espe-
cially for procedures with late start times.3–12 The inherent com-
plexity of many neurosurgical procedures further accentuates the
risk of complications as these patients are under anesthesia for
almost 80 min longer and undergo procedures nearly an hour
longer than non-neurosurgical patients.6 Furthermore, increased
operative time leads to increased operating room time, resulting
some studies have shown that resident participation in neurosur-
gical cases has negligible or possibly even beneficial effects on
patient outcomes such as length of total hospital stay, overall
complication rates, and mortality.15,16
Regardless, neurosurgical resident training is certainly a neces-
sity considering the current global shortage of neurosurgeons.17
However, as previous research has investigated outcomes in cases
with involvement of a single resident, no study has compared
two compared to one. Thus, we aimed to investigate whether two
residents scrubbed into a case was associated with increased
intraoperative complication rate, procedure length, and patient
length-of-stay.
Methods
The University of Texas Medical Branch operating room database
was queried. We reviewed patients who underwent a neurosurgi-
cal operation between January of 2013 and April of 2016 at our

CONTACT Anthony V. Nguyen antvnguy@utmb.edu School of Medicine, The University of Texas Medical Branch, 301 University Blvd, Galveston, TX
77555, USA
ß 2019 The Neurosurgical Foundation
2 A. V. NGUYEN ET AL.
institution. We included cases in which one or two residents
were scrubbed in. Operations with two residents were included
as this is the theoretical maximum number of residents that
could actively operate from start to finish with an attending sur-
geon also operating. We excluded cases in which multiple attend-
ing surgeons scrubbed in as these were likely either highly
complex cases or cases requiring multidisciplinary panels to per-
form separate procedures. Also excluded were cases involving
incarcerated patients. After compiling a list of all surgeries meet-
ing inclusion and exclusion criteria, procedures were grouped
together if they were deemed similar, such as a lumbar laminec-
tomy and lumbar laminectomy with simultaneous foraminotomy
or frontal mass resection and parietal mass resection.
Variables of interest included patient age, patient sex, day of
the week the surgery was performed, year the surgery was per-
formed, time the patient entered the room, identity of the attend-
ing neurosurgeon, number of residents scrubbed into the case,
resident experience, the patient’s length-of-stay in days prior to
surgery, and whether the attending surgeon and attending anes-
thesiologist arrived in the operating room before or at the same
time as the patient, referred to in our study as punctuality.
Analysis of resident experience was based on the experience
level of the most junior resident. If the least experienced resident
was a senior resident, which we defined as postgraduate year
(PGY)-5 to PGY-7, this was coded as ‘2,’ and if a PGY-1 to
PGY-4 was the least experienced resident scrubbed into the case,
it was coded as ‘1.’ Surgeon identity and year of the surgery were
included to control for surgeon experience, caseload, and hospital
policies possibly impacting surgeons. Time the patient entered
the room was stratified by 7 AM to 10 AM, 10 AM to 1 PM,
1 PM to 4 PM, 4 PM to 7 PM, and 7 PM to 7 AM.
Outcomes of interest were total procedure time (defined as
from time of incision to time of finishing closure) in minutes,
total time the patient was in the operating room in minutes, esti-
mated blood loss (EBL) in milliliters (mL), and post-operative
length of stay (LOS) in days. From the list of all procedures
meeting inclusion and exclusion criteria, only procedures per-
formed at least 40 times during the study period were included
for final analysis. For spinal surgeries, we additionally considered
the number of interspace levels operated upon and whether or
not resection of a mass was performed.
Table 1. Descriptive statistics for the qualifying surgeries involving one or two residents.
Age, mean (SD)
Male, n (%)
Procedure performed, n
ACDF
Craniectomy/Craniotomy for Hematoma evacuation
CSF shunt insertion
CSF shunt revision
Non-skull base, Non-posterior fossa parenchymal
Brain tumor resection
Posterior laminectomy
Procedures least experienced is seniora, n (%)
Pre-operative length-of-stay, mean (SD)b
Outcomes
Procedure length, mean (SD)c
Total operating room time, mean (SD)d
Estimated blood loss, mean (SD)e
Post-operative length-of-stay, mean (SD)b
a
For the purposes of our study, a senior was defined as a resident at least in the 5th year of a neurosurgical residency.
b
Length-of-stay is defined as total time in days the patient is in the hospital.
c
Procedure length is defined as time in minutes from skin incision to finishing of closure.
d
Total operating room time is defined as total time in minutes the patient is in the room.
e
Estimated blood loss is defined as the intraoperative blood loss estimated in milliliters.
Abbreviations: n: sample size; SD: standard deviation.
The four outcomes of interest were analyzed for each proced-
ure, independent of other surgeries, by multivariable linear
regression with an acceptable alpha of .05 determined a-priori. A
McFadden’s pseudo R2 was calculated for each linear model as
an approximation of how much variance is explained by the
model, with a maximum possible value of 1 indicating that the
outcome is predicted entirely by the variables assessed.18 On the
other hand, a lower pseudo R2 such as 0.1 would indicate that
the model has low predictive value for the outcome (10% in the
case of 0.1). All statistical analysis was performed using R-3.4.2.
This study was approved by the Institutional Review Board of the
University of Texas Medical branch (Galveston, TX, IRB 18-0046).
Results
A total of 860 procedures meeting the inclusion and exclusion
criteria during the study period were reviewed. Of these opera-
tions, six procedures were performed at least 40 times each:
anterior cervical discectomy and fusion (ACDF, n ¼ 93), lumbar
laminectomy (n ¼ 138), craniotomy or craniectomy for hema-
toma evacuation (n ¼ 92), non-skull base, supratentorial paren-
chymal brain mass resection (n ¼ 49), cerebrospinal fluid (CSF)
shunt insertion (n ¼ 53), and CSF shunt revision (n ¼ 67), total-
ing 492 procedures. Of these 492 procedures, 227 (46.1%) of
them involved only one resident scrubbed in, and 265 (53.9%)
involved two residents. The descriptive statistics of procedures
included in analysis can be found in Table 1.
Multivariable linear regression revealed that identity of the
attending surgeon and day of the week the surgery was per-
formed were the two variables significantly associated with the
greatest number of investigated outcomes (procedure time, oper-
ating room time, EBL, and post-operative LOS) across surgeries
(Table 2). Surgeon identity was significantly associated with most
studied outcomes, and day of the week was significant in about
half of the studied outcomes. For spinal surgeries, number of
interspace levels operated upon positively correlated with all out-
comes except estimated blood loss and post-operative LOS for
patients undergoing ACDF (Table 3). When the least experienced
resident was at least a PGY-5, EBL in ACDFs was approximately
38.6 mL (p ¼ .03) greater. However, an extra resident was
One resident (n ¼ 227) Two residents (n ¼ 265)
49.5 (23.8) 49.7 (22.7)
112 (49.3) 157 (59.2)
44 49
28 64
34 19
35 32
16 33
70 68
114 (50.2) 7 (2.6)
2.1 (8.5) 3.3 (15.5)
134.6 (73.1) 145.1 (73.9)
203.1 (80.6) 216.4 (86.7)
129.3 (239.9) 193.9 (376.2)
6.9 (14.4) 4.1 (6.5)
 BRITISH JOURNAL OF NEUROSURGERY 3

associated with a reduction of operative time (p ¼ .01) and oper- For non-spinal surgeries, number of residents was only signifi-
ating room utilization (p ¼ .04) by 35.1 min for lumbar laminec- cantly associated with an increase of operative length in craniec-
tomies. An association of similar magnitude was seen for tomies/craniotomies for hematoma evacuation (p ¼ .03) upon
procedure length in lumbar laminectomies when senior residents multivariable linear regression (Table 4). Having a senior resident
were the least experienced surgeon (p ¼ .02) but not total as the least experienced surgeon was associated with an approxi-
room time. mately 40 min increase in procedural length (p ¼ .003) and room
time (p ¼ .007). However, for EBL in CSF shunts, a negative cor-
relation of 16.6 mL (p ¼ .02) was seen when the most junior resi-
dent was at least a PGY-5.
Table 2. Summary, including McFadden’s pseudo R2 as an approximation for
variation explained by the model, of multivariable linear regression for
all outcomes. Discussion
Outcome Pseudo R2 Significant variables
Neurosurgical resident training in the operating room certainly
ACDF
Procedure length .69 Surgeon, Day of week, Patient sex, Levels
incurs costs and leads to longer operative time, but our study
Total room time .71 Surgeon, Day of week, Levels examined only cases in which residents were involved and sought
Estimated blood loss .36 Surgeon, Resident experience to quantify the effect of an additional resident involved in
Post-operative LOS .34 Day of week, Time patient enters room the case.2–4
Crani for hematoma For the majority of outcomes, the number of residents and
Procedure length .43 Surgeon, Number of residents,
Resident experience years of experience of those residents were not associated with a
Total room time .39 Surgeon, Resident experience significant difference. Our findings parallel the results of a study
Estimated blood loss .47 Surgeon, Day of week, Craniotomy by Lieber et al. (2016) that investigated if there was an associ-
(vs Craniectomy), Time patient enters ation between academic annual quarter and outcomes of adult
room, Pre-operative LOS
Post-operative LOS .61 Surgeon, Anesthesiologist punctuality,
neurosurgical patients.19 Both our study and theirs found no sig-
Pre-operative LOS nificant association between resident experience and morbidity,
CSF shunt insertion mortality, or efficiency.19 This may be explained by attending
Procedure length .61 Surgeon, Patient age surgeon evaluation of resident readiness and tempering of inde-
Total room time .58 Surgeon, Day of week pendence allowed.
Estimated blood loss .35 –
Post-operative LOS .41 Surgeon In our study, addition of a second resident was associated
CSF shunt revision with a 24.1 min increase in operative length for craniotomies for
Procedure length .37 Year hematoma evacuation. However, it is unclear whether this is a
Total room time .36 None causative relationship or a simple association. One possibility is
Estimated blood loss .39 Surgeon, Resident experience
Post-operative LOS .33 Resident experience, Pre-operative LOS that more residents are called to the operating room for more
Brain tumor resection complex cases such as those with larger hematomas or those
Procedure length .55 – near eloquent territories. However, there was no association
Total room time .62 Day of week between an extra scrubbed-in resident and total time spent in the
Estimated blood loss .69 Day of week, Time patient enters room
operating room, so if the extra scrubbed-in resident is directly
Post-operative LOS .90 Time patient enters room
Posterior laminectomy prolonging operative duration, intraoperative inefficiencies are
Procedure length .39 Surgeon, Patient age, Number of residents, compensated for elsewhere such as during positioning or prepar-
Resident experience, Levels ation. However, the opposite association is seen for laminecto-
Total room time .44 Surgeon, Patient age, Number of mies where an extra resident scrubbed-in is associated with
residents, Levels
Estimated blood loss .37 Day of week, Time patient enters reduced operative time and operating room utilization. Given
room, Levels that the operative field in laminectomies is relatively small,
Post-operative LOS .21 Levels potential explanations for this association include additional
Abbreviations: ACDF: anterior cervical discectomy and fusion; Crani: craniectomy retraction allowing for better visualization of structures or more
or craniotomy; CSF: cerebrospinal fluid; LOS: length-of-stay. efficient wound closure. Additional prospective studies are

Table 3. Multivariate linear regression analysis coefficients and p values for number of residents, resident experience level, and interspace levels operated upon in
spinal surgeries.
Number of residents Experience of most junior resident Interspace levels involved in surgery
Outcomes Coefficient p Value Coefficient p Value Coefficient p Value
ACDF
Procedure length þ15.8 .21 þ22.8 .11 139.6 <.001
Room time þ22.5 .11 þ23.9 .14 140.2 <.001
Estimated blood loss þ8.6 .58 138.6 .03 þ9.5 .26
Post-operative LOS 0 .95 –0.2 .74 þ0.2 .58
Posterior laminectomy
Procedure length –35.1 .01 –33.3 .02 128.8 <.001
Room time –32.9 .04 –31.5 .05 132.9 <.001
Estimated blood loss –36.9 .62 –40.1 .59 1119.1 <.001
Post-operative LOS þ6.3 .07 þ3.3 .35 12.2 .04
Bold: significant at .05 level.
Experience of most junior level was divided into two groups: (post-graduate year (PGY)-5 or above and PGY-4 or below. A positive coefficient indicates that there
was greater length of time or blood loss in the group where the most junior resident was a PGY-5 or above. A negative coefficient indicates that there was greater
length of time or blood loss in the group where the most junior resident was a PGY-4 or below.
Abbreviations: ACDF: anterior cervical discectomy and fusion; LOS, length-of-stay.
4 A. V. NGUYEN ET AL.

Table 4. Multivariate linear regression analysis coefficients and p values for number of residents and resident experience level in
non-spinal surgeries.
Number of residents Experience of most junior resident
Outcomes Coefficient p Value Coefficient p Value
Brain tumor resection
Procedure length þ32.2 .39 þ10.6 .80
Room time þ29.1 .48 –9.3 .84
Estimated blood loss –158.3 .27 –175.1 .27
Post-operative LOS þ2.7 .50 þ0.3 .94
Crani for hematoma evacuation
Procedure length 124.1 .03 139.5 .003
Room time þ15.4 .20 140.3 .007
Estimated blood loss þ130.4 .28 þ72.8 .62
Post-operative LOS –0.8 .73 –0.5 .87
CSF shunt insertion
Procedure length –15.3 .10 –6.6 .52
Room time –1.9 .87 –0.2 .99
Estimated blood loss þ1.6 .92 þ24.0 .16
Post-operative LOS þ0.4 .91 –3.7 .40
CSF shunt revision
Procedure length þ2.8 .81 –22.8 .17
Bold: significant at .05 level.
Experience of most junior level was divided into two groups: (post-graduate year (PGY)-5 or above and PGY-4 or below. A posi-
tive coefficient indicates that there was greater length of time or blood loss in the group where the most junior resident was a
PGY-5 or above. A negative coefficient indicates that there was greater length of time or blood loss in the group where the most
junior resident was a PGY-4 or below.
Abbreviations: Cran: craniotomy or craniectomy’ CSF: cerebrospinal fluid; LOS: length-of-stay.

necessary to elucidate the nature of the association between num-
ber of residents and both operative length and time spent in the
operating room.
Perhaps more interesting is the association between outcomes
and resident experience level. When the least experienced resi-
dent was a senior, EBL was increased in ACDFs and decreased in
CSF shunt revisions, procedure length was decreased in lumbar
laminectomies and increased in intracranial hematoma evacua-
tions, and total operating room utilization was longer in hema-
toma evacuations. Senior resident priority in selecting cases may
be a contributing factor, and complexity of hematomas may also
affect the association observed. Another possibility to consider is
degree of operative autonomy as an attending surgeon may be
more willing to allow greater autonomy in a safer case such as
an ACDF.20 However, autonomy of neurosurgical residents has
been affected by requiring that attending surgeons are in the
operating room and scrubbed-in for all critical portions of
a case.21
An extra scrubbed-in neurosurgical resident was associated
with longer intracranial hematoma evacuation procedural time
but decreased lumbar laminectomy operative duration and oper-
ating room utilization. Given that the number of laminectomies
analyzed in our study was greater than the number of intracra-
nial hematoma evacuations, the benefits outweighed the costs in
terms of required patient time under anesthesia and costs attrib-
utable to operating room utilization. Simultaneously training two
neurosurgical residents in the operating room may not negatively
impact patients or incur extra costs to academic institutions com-
pared to allowing only one resident to scrub in. This may repre-
sent a more effective way to train neurosurgical residents given
the current landscape of surgical education and the decrease in
resident independence within the operating room. Some institu-
tions have begun to employ and utilize mid-level providers in
order to allow residents more time in the operating room.
However, at institutions where the resident to faculty ratio is
high, multiple residents scrubbed-in concurrently is unavoid-
able.21 Other programs have established international rotations.
While the search for a more efficient and productive way to
prepare neurosurgical residents for independent practice is
underway, perhaps the easiest solution is to allow two residents
hands-on experience in the operating room when possible.
There are several important limitations of the study to note.
The retrospective nature of the study limits the ability to deter-
mine degree of resident involvement in surgery. Furthermore,
although procedures were grouped by similarity, complexity due
to more intricate details such as anatomic variation or location
of pathology were not controlled for. Additionally, differences in
individual resident skill could not be accounted for in this study.
Prospective studies controlling for these factors and investigating
whether the associations observed in this study are correlations
or causations would certainly elucidate whether an additional
neurosurgical resident operating in surgeries is a safe, cost-effect-
ive, and productive solution.
Conclusion
Two residents scrubbed-in on a case compared to one resident
was associated with lengthier operative duration of craniotomy
and craniectomies for hematoma evacuation but shorter lumbar
laminectomy procedural time and operating room utilization. An
additional resident involved in surgery was not associated with
longer operations or time spent in the operating room in other
cases. Allowing and encouraging two residents to scrub into cases
may be a safe and more cost-effective way to teach neurosurgi-
cal residents.
Acknowledgments
Preliminary data of this study will be presented at the American
Association of Neurological Surgeons 2019 Scientific Meeting.
We have no additional acknowledgments to make. All individuals
involved in this study contributed substantially from its concep-
tion to its finish.

Disclosure statement
The authors declare that there were no conflicts of interests at the times of
study conception and design, acquisition of data, analysis, writing, submis-
sion, or revision.
ORCID
Anthony V. Nguyen http://orcid.org/0000-0002-3566-2659
References
1. American Association of Neurological Surgeons, American Board of
Neurological Surgery, Congress of Neurological Surgeons, Society of
Neurological Surgeons. Ensuring an Adequate Neurosurgical Workforce
for the 21st Century; 2012. https://www.aans.org/pdf/Legislative/
Neurosurgery%20IOM%20GME%20Paper%2012%2019%2012.pdf
2. Seicean A, Kumar P, Seicean S, Neuhauser D, Selman WR, Bambakidis
NC. Impact of resident involvement in neurosurgery: an American
College of Surgeons’ national surgical quality improvement program
database analysis of 33,977 patients. Patients. Neurospine 2018;15:
54–65.
3. Bydon M, Abt NB, De la Garza-Ramos R, et al. Impact of resident par-
ticipation on morbidity and mortality in neurosurgical procedures: an
analysis of 16,098 patients. J Neurosurg 2015;122:955–61.
4. Lim S, Parsa AT, Kim BD, Rosenow JM, Kim JY. Impact of resident
involvement in neurosurgery: an analysis of 8748 patients from the
2011 American College of Surgeons National Surgical Quality
Improvement Program database. J Neurosurg 2015;122:962–70.
5. Ferraris VA, Harris JW, Martin JT, Saha SP, Endean ED. Impact of
residents on surgical outcomes in high-complexity procedures. J Am
Coll Surg 2016;222:545–55.
6. Rolston JD, Han SJ, Lau CY, Berger MS, Parsa AT. Frequency and pre-
dictors of complications in neurological surgery: national trends from
2006 to 2011. J Neurosurg 2014;120:736–45.
7. Bekelis K, Coy S, Simmons N. Operative duration and risk of surgical
site infection in neurosurgery. World Neurosurg 2016;94:551.e6–5.e6.
8. Phan K, Kim JS, Kim JH, et al. Anesthesia duration as an independent
risk factor for early postoperative complications in adults undergoing
elective ACDF. Global Spine J 2017;7:727–34.
BRITISH JOURNAL OF NEUROSURGERY 5
9. Phan K, Kim JS, Capua JD, et al. Impact of operation time on 30-day
complications after adult spinal deformity surgery. Global Spine J 2017;
7:664–71.
10. Shalev D, Kamel H. Risk of reintubation in neurosurgical patients.
Neurocrit Care 2015;22:15–9.
11. Linzey JR, Burke JF, Sabbagh MA, et al. The effect of surgical start
time on complications associated with neurological surgeries.
Neurosurgery 2018;83:501–7.
12. Golebiowski A, Drewes C, Gulati S, Jakola AS, Solheim O. Is duration
of surgery a risk factor for extracranial complications and surgical site
infections after intracranial tumor operations? Acta Neurochir 2015;
157:235–40.
13. Childers CP, Maggard-Gibbons M. Understanding costs of care in the
operating room. JAMA Surg 2018;153:e176233
14. Raft J, Millet F, Meistelman C. Example of cost calculations for an
operating room and a post-anaesthesia care unit. Anaesth Crit Care
Pain Med 2015;34:211–5.
15. Lakomkin N, Hadjipanayis CG. Resident participation is not associated
with postoperative adverse events, reoperation, or prolonged length of
stay following craniotomy for brain tumor resection. J Neurooncol
2017;135:613–9.
16. Kim RB, Garcia RM, Smith ZA, Dahdaleh NS. Impact of resident par-
ticipation on outcomes after single-level anterior cervical diskectomy
and fusion: an analysis of 3265 patients from the American College of
Surgeons National Surgical Quality Improvement Program database.
Spine (Phila Pa 1976) 2016;41:E289–296.
17. Dewan MC, Rattani A, Fieggen G, et al. Global neurosurgery: the cur-
rent capacity and deficit in the provision of essential neurosurgical
care. Executive Summary of the Global Neurosurgery Initiative at the
Program in Global Surgery and Social Change. J Neurosurg 2018;130:
1–10.
18. Faraway J. Extending the linear model with R: generalized linear, mixed
effects and nonparametric regression models. 1 ed. Boca Raton, Florida,
USA: Chapman and Hall/CRC; 2005.
19. Lieber BA, Appelboom G, Taylor BE, Malone H, Agarwal N, Connolly
ES. Jr. Assessment of the “July Effect”: outcomes after early resident
transition in adult neurosurgery. JNS 2016;125:213–21.
20. Feng Y-T, Hwang S-L, Lin C-L, Lee IC, Lee K-T. Safety and resource
utilization of anterior cervical discectomy and fusion. Kaohsiung J Med
Sci 2012;28:495–9.
21. Kim DH, Dacey RG, Zipfel GJ, et al. Neurosurgical education in a
changing healthcare and regulatory environment: a consensus state-
ment from 6 programs. Neurosurgery 2017;80:S75–S82.