Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
Under what circumstances would you consider doing a cervical disc arthroplasty for management of cervical myelopathy?
I have usually been of the opinion that, in cervical myelopathy, allowing for continued motion at a segment by performing a disc arthroplasty seems counterintuitive; however, with this paper showing non-inferior results from disc arthroplasty, I am quite willing to change my thinking. I think in the...
How do you determine if the occipital condyle needs to be drilled during a far lateral approach for an intradural lesion?
The determination to drill the occipital condyle depends on the location and size of the lesion; for example, for very large lesions that have already displaced the brainstem quite a bit more posteriorly or contralaterally, condylar drilling is not needed. This can generally be determined on an axia...
How do you determine which patients should receive an endoscopic strip craniectomy?
In my view, the candidate for endoscopic strip craniotomy should ideally be less than four months of age at the time of surgery, and the family must commit faithfully to a molding helmet for up to a year.
How do you decide on head-of-bed positioning after mechanical thrombectomy for acute stroke?
First, there is some evidence that HOB positioning is related to deterioration/improvement before endovascular thrombectomy (EVT) from the ZODIAC trial. Second, safety comes first. Follow your ABCs. If the airway is ok, the patient does not develop orthopnea with a supine position, and the BP is ok ...
Do you wait to treat small asymptomatic brain metastases until they reach a certain size?
I typically treat all lesions on MRI that are found to be concerning for brain metastases. This is after a discussion with our neuroradiologist colleagues. If there is uncertainty that a small lesion may not be a brain metastasis, then I will elect to follow with a surveillance MRI and treat in the ...
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...
Does CEA still have a role instead of stenting for surgical management of asymptomatic carotid artery disease?
In most patients with asymptomatic high-grade stenosis, stenting is preferable to endarterectomy based on the results of CREST-2. In a small percentage of such patients, stenting may not be technically feasible. Also, some patients may not want to take the medications usually prescribed after stenti...
What first-line therapeutic regimen do you consider most appropriate for metastatic clear cell renal carcinoma presenting with brain metastasis and vasogenic edema?
For patients presenting with brain metastases, I always do local therapy, usually SBRT, before systemic therapy. I am nervous about starting immune-based therapy or a TKI in patients with uncontrolled CNS metastases. There are small series using TKIs such as cabozantinib in this setting, but since S...
Has MR spectroscopy ever led you to forego a planned stereotactic biopsy in a patient with a suspected intracranial neoplasm?
I have never had spectroscopy allow me to forego a stereotactic biopsy when I suspected active/progressive neoplasm; however, if I suspected necrosis more than recurrence or tumor and spectroscopy was in accordance with that, then I have been able to save people a biopsy in that situation.
Do you incorporate MR Spectroscopy into preoperative planning for brain biopsies for suspected new brain tumors?
Yes, when possible.