Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
What patient factor led to performing a direct bypass rather than an indirect bypass for treatment of moyamoya?
The honest answer is that the evidence for selecting a direct or indirect bypass is limited and imperfect. There are no large randomized controlled trials and most data comes from retrospective cohort studies and meta-analyses. The key factors favoring direct bypass for moyamoya are age, cerebrovasc...
What is your treatment strategy for pregnant patients with newly discovered prolactinomas?
There are a few factors in this decision, with lots of subtle variations. Some factors to consider are: 1) how big is the tumor (microadenoma versus macroadenoma), and 2) are there any symptoms other than elevated prolactin (e.g., visual field defect)? Assuming there are no major compressive symptom...
For patients who have 4 levels of ventral cervical compression, how do you determine whether to do an anterior or posterior approach?
If most of the pathology is anterior, then I go anterior. Most of the time, this is the case. If it’s posterior, then I go posterior. Rarely would I need to do both.
In patients with medically-refractory left temporal epilepsy, and left dominant language and memory, how should you approach surgical intervention?
Dominant temporal lobe epilepsies are often not candidates for hippocampal ablation or anterior temporal lobectomy because the risk for memory decline is deemed to be too high. Although having left temporal lobe epilepsy does not rule out the possibility of a resective/ablative surgery, in your part...
Under what circumstances would you place an EVD for Hunt Hess 1 or 2 patients with subarachnoid hemorrhage secondary to a ruptured cerebral aneurysm?
I would place an EVD for a ruptured aneurysm in patients who are clinically doing very well (Hunt Hess 1 or 2) if they have imaging evidence of ventriculomegaly.
Under what circumstances would you consider decompression alone for a stable grade 1 spondylolisthesis at L5-S1?
In general, a decompression alone can be performed in select cases in the setting of a degenerative spondylolisthesis in the absence of instability. Primary symptoms from spinal stenosis must be present and not related to foraminal height or foraminal stenosis in my practice. I look at the sacral sl...
How do you factor in pain catastrophizing in your decision to pursue surgery for degenerative lumbar spondylolisthesis?
I am a firm believer that surgery is the last resort for our patients. There are wants and needs in life and surgery for degenerative lumbar spondylolisthesis is elective surgery. Patients with severe pain in my practice still undergo all conservative measures. We work on preoperative optimization w...
How do you determine which site to utilize for ventricular peritoneal shunt placement - frontal or posterior?
Depends on the individual, anatomy, size, prior surgeries, etc. Preference is frontal for several reasons: with growth, the relative length of the catheter to overall head growth is less than with a parieto-occipital catheter and less likely to end up in the choroid plexus. Should septostomy be need...
How do you change the shunt setting after adding an antisiphon device?
In my practice, if I add an antisiphon device, I do not change the programmable valve setting at the time of surgery. I only adjust the setting based on patient symptoms several weeks to allow the patient to adjust to the new system.
How do you approach treatment of a glioblastoma in pregnancy?
Glioblastoma during pregnancy could be treated safely (to mother and fetus) with certain precautions and modifications. Collaboration and consultation with the patient’s obstetrician are essential. External shielding over the patient’s abdomen during treatment will decrease the external scatter radi...