Background: Approximately 95,000 Ontarians, including nearly 15,000 children, have a diagnosis of epilepsy (CCSO, 2015). Management is typically with medication, though surgical resection offers permanent cure in a subsection of patients. A 2012 Health Quality Ontario study estimated a potential 9,300 patients as surgical candidates, but only 150 operations are performed annually, suggesting the surgery option is underutilized. This study attempts to identify reasons for non-referral in a small epilepsy practice. Methods: Evidence based guidelines (Jette, N et al, CMAJ 2014) were used to define eligibility for surgical referral in 274 children with epilepsy. The presence of referral criteria was analyzed. Results: 22 children had clear evidence of drug resistance and one other criteria for referral for epilepsy surgery. 10 referrals had been made. Complex syndromes were present in 40% of the referrals, and 10% of the unreferred. Surgical lesions were present on MRI in 60% of the referrals and 14% of the unreferred. The majority of the unreferred have refractory focal epilepsy but no known surgical abnormality on MRI. Conclusions: In our practice there is a referral bias towards patients with MRI lesions, whereas those without MRI findings tend not to be referred, despite being refractory.

Background: Brain imaging in asphyxiated newborns treated with hypothermia has shown that brain injury can be identified as early as day 2 of life and continue to evolve over the first month of life. Methods: Asphyxiated newborns treated with hypothermia were enrolled prospectively. Apparent diffusion coefficient (ADC) and fractional anisotropy (FA) were measured on magnetic resonance imaging (MRI) performed over the first month of life. Neurodevelopment was evaluated around 2 years of age. Results: Twenty-six asphyxiated newborns treated with hypothermia were enrolled. In asphyxiated newborns treated with hypothermia, who developed cerebral palsy, ADC values were significantly decreased on day 1 of life, on day 2-3 and around day 10 of life in the thalamus. In the same newborns, the FA values were significantly decreased on day 10 of life. Conclusions: Early MRI measurements permitted to identify the newborns developing cerebral palsy as early as on day 1 of life and could thus be used in the future to predict the long-term neurodevelopmental outcome asphyxiated newborns treated with hypothermia.

Glioblastoma (GBM) is the most common brain cancer. Most GBM tumors have unmethylated promoter status for O6-methylguanine-DNA-methyltransferase (MGMT); a validated biomarker for MGMT protein-expression and ensuing temozolomide-resistance. Second-line treatment with bevacizumab has not improved overall survival (OS). Dianhydrogalactitol (VAL-083) is a bi-functional alkylating agent targeting N7-Guanine, thus MGMT-independently inducing interstrand cross-links, DNA double-strand breaks and cell-death in GBM cell-lines and cancer stem cells. VAL-083 is currently in Phase I/II clinical trial for recurrent GBM, post-TMZ and post-bevacizumab. In this Phase II clinical trial, the main goal is to assess the 9-month OS in MGMT-unmethylated, recurrent, bevacizumab-naive GBM. RATIONALE: The vast majority of GBM patients experience recurrent/progressive disease within a year from initial diagnosis and median survival after recurrence is 3-9 months. Chemotherapy regimens for these patients are lacking and there is a significant unmet medical need. Given VAL-083’s novel alkylating mechanism, promising clinical benefit, and favorable safety profile, a trial studying VAL-083 in MGMT-unmethylated recurrent GBM is warranted. METHOD: Randomized, non-comparative biomarker-driven Phase II clinical trial in MGMT-unmethylated GBM patients at first recurrence/progression, prior to bevacizumab. 48 patients will be randomized to receive VAL-083 or “standard-of-care” salvage drug lomustine. 32 patients will receive VAL-083 40mg/m2/day on days 1,2,3 of a 21-day cycle. 16 patients will receive lomustine 90 mg/m2/day on day 1 of a 42-day cycle. Patients will be followed until death or for at least 9 months from enrollment, whichever occurs earlier. Survival will be compared to the BELOB trial for recurrent MGMT-unmethylated GBM patients treated with lomustine.

Disparities in cancer survival rates have been identified for rural patients in Canada and are thought to be due to inequities in access to care. The objective was to perform the first examination of urban and rural brain cancer survival in Canada. Methods: A population-based retrospective cohort study was performed using Canadian Cancer Registry data for patients diagnosed with a primary brain cancer from 1996-2008. Seven major brain cancer histology groups used were glioblastoma, diffuse astrocytoma, glioma (not otherwise specified), oligodendroglioma, anaplastic astrocytoma, oligoastrocytic tumours, and anaplastic oligodendroglioma as categorized by the Central Brain Tumor Registry of the United States (CBTRUS). Kaplan-Meier (KM) survival estimates and Cox Proportional Hazards Regression were performed, adjusting for sex, histology, age group, region, and urban-rural residence. Rural residence was defined using Statistics Canada’s “Rural and Small Town” definition of living in a region with a population of less than 10,000 people. Results: No significant difference between urban and rural residence was identified in crude KM survival estimates. Though not significant, 5-year survival was generally better among rural residents than urban residents, except for rural residents with anaplastic astrocytoma. There remained no significant difference for Cox hazard ratios after adjustment for age, sex, or region. Conclusions: This is the first study to examine the effect of urban-rural residence on brain cancer survival. No significant differences for any histology were found, indicating equitable access to care for brain cancer patients in Canada, regardless of their location of residence.

Background: Genetic leukoencephalopathies are a group of neurodegenerative diseases imposing a great burden on patients and families. There is no previous systematic study looking at the impacts of these diseases. Methods: HRQOL was assessed using the Pediatric Quality of Life Inventory (PedsQL) model. A total of 24 patients with genetically determined leukoencephalopathies and their family members completed the PedsQL questionnaires. Detailed clinical assessments were performed at the time the questionnaires were filled. HRQOL results were correlated with the severity of the clinical features and the presence vs. absence of a definitive molecular diagnosis. Results: Preliminary results show lower PedsQL total scores for patients without compared to with a molecular diagnosis. Emotional and physical functioning scores were significantly impaired in patients without a molecular diagnosis. Lower total scores were obtained for patients who presented more severe clinical features such as lost ambulatory functions and dysphagia. Conclusions: Overall, our preliminary results indicate that patients without a molecular diagnosis have an impaired HRQOL and that more severely affected patients have a poorer HRQOL. Further analyses and studies on a larger population of patients in a prospective fashion are required to assess the burden of these diseases and identify potential modifiable factors.

Background: 4H or POLR3-related leukodystrophy is an autosomal recessive disorder characterized by hypomyelination, hypodontia and hypogonadotropic hypogonadism caused by mutations in POLR3A, POLR3B and POLR1C. The endocrine abnormalities have never been systematically studied. Methods: A cross sectional international multicenter study was performed and the following variables were assessed: weight, height, head circumference, pubertal history, hormone levels and neurological and non-neurological features. Data was analyzed to determine whether there was a correlation between the presence of endocrine abnormalities and mutations in a specific gene and/or the presence of specific symptoms such as other non-neurological symptoms. Results: Data was collected on 156 patients. Endocrine data were available for 144 patients. The most common endocrine abnormalities seen in this cohort were short stature (54/90 patients (60%)) and delayed puberty (53/70 patients (76%)). 13 of the 58 patients tested (22%) had abnormal thyroid function. Patients with POLR3A mutations were more likely to have endocrine abnormalities. Conclusions: Our results confirm that the most common endocrine features in 4H leukodystrophy are short stature and pubertal abnormalities. However, the other potential endocrine abnormalities are typically under-investigated in this patient population. A prospective study is required to investigate the extent and severity of the endocrine abnormalities in 4H leukodystrophy.

Tumor treating electric fields (TTFields) are an established treatment for glioblastoma patients. But the anatomical and physical characteristics of the brain and tumor contributing to treatment efficacy are unknown. We contoured gross tumor volume (GTV) using ScanIP and measured tumor size according to the RANO criteria on 5 patients with recurrent glioblastomas who benefited from TTFields (cohort 1) and 5 who did not (cohort 2). Tumor surface area and geometric centroid distance (GCD) from the bilateral ventricles were computed. Wilcoxon rank sum test was used to compare these physical parameters between the two cohorts. The results showed that the respective median GTV was 11.6cm3 and 38.1cm3 (P=0.0591), while the respective median GCD was 5.0cm and 5.3cm (P=0.6761), in cohort 1 and 2. The tumor size had a median of 8.2cm2 in cohort 1, as compared to a median of 53.9cm2 in cohort 2 (P=0.0591). The surface area had a median of 56.2cm2 in cohort 1, as compared to a median of 214.0cm2 in cohort 2 (P=0.4034). After removing an outlier from cohort 1 and another from cohort 2, the respective median GTV was 9.7cm3 and 41.3cm3 (P=0.1003), and the respective median surface area was 46.5cm2 and 236.0cm2 (P=0.0304). The respective median surface area/GCD was 13.3cm and 38.9cm (P=0.0304) and the respective median GTV/GCD was 2.7cm2 and 8.5cm2 (P=0.0304). The data suggest that the ratio of surface area/GCD and GTV/GCD, which are proportional to the tissue capacitance, may be an important parameter for optimizing TTFields efficacy in the treatment of glioblastoma.

New enhancing lesions after surgery and chemoradiation for high grade glioma commonly contain variable proportions of tumor recurrence (TR), tissue necrosis and treatment related changes. Our purpose is to determine whether the pattern of contrast enhancement and perfusion MR parameters correlate with the percentage of TR in these lesions. Methods: We prospectively enrolled 30 patients with high grade gliomas who presented with a new enhancing lesion suspicious for tumor recurrence. Each patient underwent conventional MRI with DCE and DSC perfusion MRI. The pattern of enhancement was classified by a blinded neuroradiologist in 5 different categories (solid, focal nodular, peripheral rim, hazy, punctate). A hot spot region-of-interest analysis was performed for each parametric map (Ktrans, AUC, Vp, corrected CBV). TR percentage was defined histopathologically. The lesions were categorized into predominant TR (=tumor>70%), predominant treatment related changes (T=<35%) and mixed lesions (35 %< T=<70%). Differences between the groups were assessed via Kruskal-Wallis and Mann-Whitney U tests. Results: There were 32 lesions (4 predominantly treatment related lesions,5 mixed lesions,23 predominant tumor recurrence). There is no significant difference in the enhancement pattern between the three groups (p=0.18).Statistically significant difference was only seen for corrected CBV between the three groups (p=0.01), mainly between the mixed and predominant tumor groups. The rest of the perfusion parameters did not show a statistically significant difference between the groups(p>0.05). Conclusion: Corrected CBV might be useful in predicting the proportion of tumor recurrence in post-treatment high grade gliomas.

Background: Sarcoidosis is a multiorgan autoimmune disease characterized by the presence of non-caseating granulomas. The diagnosis can be difficult, particularly with central nervous system (CNS) involvement, and pathology outside of the CNS has to be carefully evaluated. Early and correct diagnosis is crucial for appropriate management particularly in children where sarcoidosis and neurosarcoidosis are rare. Methods: We describe a 16 year old previously healthy boy who presented with progressive pyramidal neurological signs and symptoms localizable primarily to the brain stem. Results: Initial imaging revealed striking brainstem, as well as cerebral, cerebellar and spinal cord perivascular enhancement. Lung involvement was subclinical with a miliary pattern on chest imaging and needle biopsy revealed an interstitial lymphocytic infiltration. Extensive serum and CSF rheumatological, autoimmune and infectious investigations were noncontributory. Serum ACE levels were at first within normal limits. Steroid treatment stabilized symptoms and perhaps coincidentally, separate rituximab treatments were followed within days by vertigo (with a new pontine lesion) or a respiratory decompensation. A wedge lung biopsy revealed granulomatosis. Current treatment consists of mycophenolate, methotrexate with a prednisone wean. Conclusions: This case report reinforces the varied manifestations and mimics of sarcoidosis (including CLIPPERS) and highlights the need for a high index of suspicion despite apparently negative investigations.

This study aims to evaluate the impact of preoperative functional magnetic resonance imaging (fMRI) on low grade glioma (LGG) patients’ outcomes and surgical planning. Methods In this retrospective matched cohort study of a single surgeon’s patients, we are comparing two groups of LGG patients (WHO grade II) based on exposure to fMRI. Sixteen LGG patients who underwent fMRI were selected, and 32 control (non-fMRI exposed) patients are being selected through propensity score matching from a pool of 764 brain tumour patients. To assess the impact of fMRI data on clinicians’ decision making process, neurosurgeons within a single centre are completing questionnaires regarding treatment options for each LGG fMRI patient based on clinical data and structural imaging before and after fMRI. Results Within the group of 16 LGG patients who have undergone fMRI studies over a 12-year period, most patients presented with seizures (81 percent), and most lesions were left-sided (81 percent) and frontal (75 percent). Patients underwent either craniotomy (50 percent), stereotactic biopsy (25 percent) or nonsurgically management (25 percent). In surgical patients, between presurgical assessment and eight week post-surgical follow-up, mean modified Rankin scale improved from 1.80 (sd 0.79) to 1.50 (sd 0.97). In our cohort, 5-year mortality was 12.5 percent (mean follow-up duration 5.46 years). Conclusions Data analysis is ongoing with plans to compare relevant patient demographics and outcomes, and to analyse questionnaires to elucidate how surgeons incorporate fMRI data into their therapeutic approach.

Background: We investigated motor function associations with age, gender, and D4Z4 fragment size among participants with infantile FSHD. Methods: We collected standardized motor assessments including goniometry, manual muscle testing (MMT), quantitative muscle testing (QMT), and FSHD clinical severity scores (CSS) at 12 CINRG sites. To measure associations, we used linear regression models adjusted for age at enrollment, onset of weakness, gender, and D4Z4 repeats. Results: 53 participants (59% female, mean age 23.1±14.6 years) were enrolled. Weakness was most pronounced at the shoulder girdle and rectus abdominis (median MMT 30-38% of normal). Older enrollment age was associated with greater CSS (p=0.005) and reduced range of motion in shoulder abduction, shoulder flexion, elbow flexion, and ankle dorsiflexion (all p<0.01). Females and participants with larger D4Z4 repeats had milder shoulder/arm weakness and lesser disease severity (all p<0.05). Increased age at onset of facial weakness was significantly associated with greater total muscle strength, as measured by QMT and MMT (both p=0.002). Conclusions: We confirm the descending pattern of muscle involvement and milder disease severity in females or those with larger D4Z4 repeats. Furthermore, earlier age at onset of facial weakness was associated with greater muscle weakness. Future longitudinal assessments will describe rates of disease progression in this population.

This study aims to evaluate reliability of clinical functional magnetic resonance imaging (fMRI) in identifying language lateralisation index (LI), verified with Edinburgh handedness inventory (EHI), in brain tumour patients. Methods In this retrospective study, 31 of a single surgeon’s brain tumour patients over a 12 year period have been selected. Lesion type varied, 12 (39 percent) were high grade gliomas, 10 (32 percent) low grade gliomas, 3 (10 percent) meningiomas, and 6 (19 percent) other types. Patients underwent language fMRI paradigms for preoperative assessment, and a neuroimaging analyst was able to identify an LI value for at least one Brodmann area (BA). For each paradigm, a neuroimaging analyst attempted to calculate LI for Wernicke’s area (BA 22) and Broca’s area (BA 44 and 45). Results Of 113 total LI values, 66 (58 percent) were concordant to EHI-predicted hemispheric dominance. Reliability of language LI appears dependent upon the type of language task performed. Verb generation correctly identified Broca’s area in 18 patients (64 percent) and Wernicke’s area in 11 patients (61 percent), sentence completion correctly identified Broca’s area in 18 patients (72 percent) and Wernicke’s area in 9 patients (60 percent), and naming correctly identified Broca’s area in 7 patients (47 percent) and Wernicke’s area in 3 patients (27 percent). Conclusions Results show limited correlation between language LI determined by fMRI and EHI. The main limitation of this study is that language LI is being compared to EHI, rather than gold standard measure of hemispheric dominance (e.g. Wada).

Background: The Supreme Court of Canada (SCC) recently rendered a decision striking down the Criminal Code absolute prohibition on providing assisted dying. End of life decisions are commonly encountered by neurosurgeons due to the nature of their practice. Neurosurgeons will be faced with patients requesting PAD in the near future. Methods: The recent SCC ruling heralds a change that will radically alter a most basic tenet that has historically guided physicians and surgeons. A subcommittee of the Canadian Neurosurgical Society (CNSS) was formed to generate a position statement to reflect the interests of both neurosurgeons and their patients. Results: Fundamental issues regarding the implementation of PAD identified include:

Clarity of legislation

The creation of an independent, third party referral service

Effective safeguards and oversight of the entire process

-The right to “conscientious objection” on the part of hysicians who do not wish to be involved in PAD

Conclusions: The CNSS urges clarity in legislation regarding PAD and strict oversight in its implementation to reduce potential harm. We also support the creation of an independent, third party referral service which would serve to respect the conscience of those health care providers who do not wish to actively participate in PAD.

Background: The goals of evidence-based neurosurgery are to improve surgical outcomes, reduce complications, and provide an objective basis for altering practice. The need for higher quality studies, typically prospective and multicentre, has been growing especially in light of the evolving complexity of neurosurgical interventions and heterogeneity of patient populations. In the United Kingdom (UK), trainee-led research collaboratives have been established to tackle this problem. Therefore, we sought to evaluate the potential role for a resident-led research collaborative in neurosurgery in Canada based on the UK experience. Methods: A literature review of trainee-led collaboratives was conducted utilizing PubMed and Medline. Identified articles were reviewed for study quality and clinical relevance to explore the potential benefits of collaboratives. Results: In the UK, 27 collaboratives have been established in various specialties by trainees. Some published high quality trials with implications on their clinical fields. Evidence suggests that such endeavors improves trainees’ research skills and may help cultivate a research culture tailored towards clinical trials. Conclusions: Given the growing evidence for research collaboratives in the UK, we propose launching the Canadian Neurosurgery Research Collaborative (CNRC) which currently represents 12 out of 14 neurosurgery programs in Canada, and planning its first multicenter prospective study.

Primary CNS Lymphoma (PCNSL) is an unusual extranodal form of Non-Hodgkin’s lymphoma with a locally aggressive course but a rare tendency to disseminate systemically. It has been documented in that the clinical characteristics and response to treatment among Asians is comparable to the Western population yet no studies done locally are available. Objectives: This study aims to determine the clinico-pathologic profile of patients diagnosed with PCNSL seen at Philippine General Hospital (PGH) from January 2006 to September, 2014 and to evaluate the patients’ response to the following treatment modalities: 1) Combination chemotherapy 2) Chemo-RT 3) Single agent chemotherapy and 4) no specific anti-lymphoma treatment. Methodology: This is a descriptive and retrospective study that included all cases of histologically-proven PCNSL seen at the PGH from January 2006 to September, 2014. The clinical profile, imaging studies and biopsy findings were obtained from the patient records. The survival rates at the end of one and two years of diagnosis were computed. Results and Conclusion. Among patients diagnosed with PCNSL at PGH, there is a higher incidence of PCNSL among males with a male to female ratio of 1.4:1 and have a younger onset with a median age of 50.2 years. Most patients presented with signs of increase ICP and majority had solitary cortical lesions with histopathologic diagnosis of diffuse large B cell lymphoma. Patients who did not undergo any form of treatment had a mean survival of 10 months. Immunocompromised patients had a shorter life-span with a mean survival of 7.5 months. Treatment of combination chemotherapy with HD-MTX and Rituximab had the most favorable outcome followed by HD-MTX only with a 2 year survival rate of 100% and 66% respectively while patients who underwent chemo-RT had a 2 year survival rate of 33% with a high incidence of neurocognitive delay.

Background: In contrast with 56% of US medical schools, most Canadian medical schools do not offer a required clerkship neurology rotation. This study aims to assess the need for additional clinical neurology training in Quebec medical schools. Methods: Third and fourth year medical students from the province of Quebec completed surveys inquiring about accumulated theoretical teaching time, clinical neurology exposure, self-reported neurological examination proficiency and interest in additional training. Results: 66 students answered the survey. 43% were from Université de Montréal, 18 % from McGill University, 14% from Université Laval and 24% from Université de Sherbrooke. For theoretical teaching, 44% reported at least 60 hours (h) of teaching, 44% reported 40 to 60 h and 23% reported 10 to 40 h. For clinical exposure, 24% reported at least 60 h, 8% reported 40 to 60 h, 40% reported 10 to 40 h and 29% reported less than 10 h. Most students reported being comfortable with their neurological examination skills (58%) but still 41% were uncertain or felt uncomfortable. 80% indicated interest in receiving additional clinical exposure. Conclusions: Amongst Quebec medical students, clinical neurology exposure is likely insufficient. An important proportion of students remain uncomfortable with the neurological examination and most students are interested in additional neurological training.

Primary intracranial sarcoma among patients diagnosed with HIV is rare. Case reports published have shown that there is an increasing number of cases of leiomyosarcoma, hemangiopericytoma and rhabdomyosarcoma among these patients. Further, there are also few reports that sarcomas may present atypically, sometimes mimicking a brain abscess. We report a case of a 26 year old male, newly diagnosed HIV, who presented with bilateral chronic suppurative otitis media associated fever, headache and vomiting. Neuroimaging showed with multiple rim enhancing masses on the left temporal, parietal and occipital areas and bilaterally sclerosed mastoid air cells. Initial impression was an otogenic abscess. Burrhole craniotomy and evacuation of the cystic masses was done. Histopathologic examination revealed a small round blue cell sarcoma. Different immunostains were done to differentiate the various subtypes of sarcomas possible. Patient was discharged improved but did not consent to chemotherapy or radiotherapy.

Primary CNS Lymphoma (PCNSL) is an unusual extranodal form of Non-Hodgkin’s Lymphoma with a locally aggressive course but a rare tendency to disseminate systemically. There are various modalities available for the treatment of PCNSL which include chemotherapy, radiotherapy, surgery and immunotherapy. The effectiveness of adding another anti-neoplastic agent to HD-MTX have been optimized in small scale studies yet the “ perfect combination” has yet to be elucidated Objectives: This study aims to 1) compare the response to treatment of monotherapy with high-dose Methotrexate (HD-MTX) versus HD-MTX and an additional anti-neoplastic agent by evaluating complete response, partial response, stable disease and disease progression and 2) to compare the hematologic and non-hematologic side effects among patients subjected to monotherapy vs combination chemotherapy. Methodology: Journals from Medline, EMBASE, Cochrane Central Register of Control Trials (CENTRAL) and other relevant websites (www.clinicaltrials.org) without any restrictions in the year, language and status of publication were searched. Literatures cited by eligible studies and systemic reviews were also checked to identify useful articles. The following Medical Subject Headings (MeSH) were used: ‘primary CNS lymphoma’, ‘treatment’, ‘chemotherapy’ and ‘randomized control trial’. Statistical analysis was performed using the RevMan software version 5.1. Odds ratio (OR) and 95 % confidence interval (95% CI) were used as summary statistics. Results and Conclusion: The use of high-dose methotrexate and another anti-neoplastic agent showed benefit in terms of achieving complete response and delaying disease progression among patients diagnosed with PCNSL. However, the risks of hematologic toxicities such as anemia, neutropenia, thrombocytopenia and infection was higher in patients treated with the combination chemotherapy. Significant non-hematologic side effects such as mucositis was also observed in patients receiving an add-on to high dose methotrexate.

Background: Deliberate practice is one aspect of gaining competency in surgical skills. We have previously integrated a vascular microsurgery module into our residency training curriculum, and have recently described our experience with constructing patient-specific spine models for simulating lumbar spinal durotomy repair. The goal of this project is to develop the necessary infrastructure to facilitate practice on the spine model during residency. Methods: A 3D-printed plastic lumbar spine model was created from a patient computed tomography scan. L2 was manually laminectomized, and paraspinal tissues were simulated using Polyvinyl Chloride (PVC) Plastisol. Harvested bovine pericardium was sewn into tubular form as a dural substitute. The pericardial tubes were tied at either end and attached to intravenous tubing to create a closed loop water system. Results: We are developing a video tutorial describing how to setup and use the model. Residents will be recorded while performing a 1.5 cm durotomy and repair using a surgical microscope available in our training laboratory (Drake-Hunterian Neurovascular Laboratory, London, Ontario, Canada). Residents are asked to grade the realism of the model using a questionnaire. Metrics of quality are to be determined. Conclusions: Our proposed model is a cost-effective, easy-to-prepare lumbar spinal simulator that facilitates microsurgical practice during neurosurgical residency.

Background: Industry involvement in neurosurgical research is common, creating financial conflicts of interest (COIs). Most journals require voluntary disclosure of financial COIs. In 2013, the Sunshine Act (SA) was passed in the US, mandating industry disclosure of all payments to physicians. The accuracy of voluntary disclosure can now be determined by comparing voluntary author disclosure with industry data. Methods: We reviewed disclosure statements and calculated rates of voluntary disclosure in major neurosurgical journals before (2011) and after (2013) the Sunshine Act to determine if voluntary disclosure increased after its implementation. We then determined the accuracy of voluntary disclosure in 2013, comparing voluntary disclosure with industry disclosure on the Open Payments Database (OPD). Mean, median and range of industry payments to neurosurgeons were calculated Results: Voluntary disclosure significantly increased in JNS-Spine only (10.7% to 35.4%,p<0.001) after implementation of the SA. The average rate of non-disclosure in all journals studied was 38.3% (Range 33.8%-42.2%)

$32,598,522.97 of industry payments were provided to 656 authors in the five-month period studied (Average $49,692.87/author) Conclusions: Voluntary COI disclosure in JNS- Spine increased after implementation of the Sunshine Act. Industry payments to physicians publishing in neurosurgery journals are common and rates of non-disclosure of COIs are high. The ethical implications of COIs and non-disclosure are discussed.